MEDICARE: DOUGLAS VANGORDON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	204C00000X	Sports Medicine (Neuromusculoskeletal Medicine) Physician	15-00002769	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558719369
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOUGLAS VANGORDON

Provider Business Mailing Address
First Line	:	2200 NE NEFF RD
Second Line	:	SUITE 200
City	:	BEND
State	:	OR
Zip	:	97701-4283
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2245 NW SHEVLIN PARK RD
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97703-7195
Country	:	US
Telephone Number	:	541-382-3344
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2016
Last Update Date	:	06/02/2016

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Directions to “ DOUGLAS VANGORDON ” Practice Location

Language	Start Address	Practice Location

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