1861525792 NPI number — DR. DONNA DIANNE STOVALL URSTADT MD

Table of content: DR. DONNA DIANNE STOVALL URSTADT MD (NPI 1861525792)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861525792 NPI number — DR. DONNA DIANNE STOVALL URSTADT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
URSTADT
Provider First Name:
DONNA
Provider Middle Name:
DIANNE STOVALL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GABLE
Provider Other First Name:
DONNA
Provider Other Middle Name:
DIANNE STOVALL
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1861525792
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 597
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YAMHILL
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97148-0597
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-662-5007
Provider Business Mailing Address Fax Number:
503-681-1903

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
335 SE 8TH AVE
Provider Second Line Business Practice Location Address:
TUALITY COMMUNITY HOSPITAL PATHOLOGY DEPARTMENT
Provider Business Practice Location Address City Name:
HILLSBORO
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-681-1150
Provider Business Practice Location Address Fax Number:
503-681-1903
Provider Enumeration Date:
03/13/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X , with the licence number:  MD 19683 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207ZP0102X , with the licence number: 030461 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0102X , with the licence number: 14495 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 133956 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".