MEDICARE: PONDEROSA MEDICAL

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	207R00000X	Internal Medicine Physician	MD12002	OR

General Provider Information

NPI Number	:	1710931274
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PONDEROSA MEDICAL

Provider Business Mailing Address
First Line	:	1558 SW NANCY WAY
Second Line	:	SUITE 101
City	:	BEND
State	:	OR
Zip	:	97702-3216
Country	:	US
Telephone Number	:	541-312-8679
Fax Number	:

Provider Business Practice Location Address
First Line	:	1558 SW NANCY WAY
Second Line	:	SUITE 101
City	:	BEND
State	:	OR
Zip	:	97702-3216
Country	:	US
Telephone Number	:	541-312-8679
Fax Number	:

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	GILBERT B LEE
Credential	:	MD
Telephone Number	:	541-312-8679

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	08/22/2020

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Directions to “PONDEROSA MEDICAL ” Practice Location

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