1245221084 NPI number — WILLAMETTE DERMATOLOGY, P.C.

Table of content: (NPI 1245221084)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245221084 NPI number — WILLAMETTE DERMATOLOGY, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLAMETTE DERMATOLOGY, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245221084
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 23200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97281-3200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-691-1743
Provider Business Mailing Address Fax Number:
503-691-0983

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19875 SW 65TH AVE
Provider Second Line Business Practice Location Address:
SUITE 260
Provider Business Practice Location Address City Name:
TUALATIN
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97062-8353
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-691-1743
Provider Business Practice Location Address Fax Number:
503-691-0983
Provider Enumeration Date:
11/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KLAS
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
503-691-1743

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  MD21432 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DG7086 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 151278 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1508999152 . This is a "INDIVIDUAL PROVIDER NPI" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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