Healthcare Provider Details

I. General information

NPI: 1427510148
Provider Name (Legal Business Name): WILLEM O. SPEED MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 12/30/2022
Certification Date: 12/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 SW SIMPSON AVE STE 110
BEND OR
97702-3789
US

IV. Provider business mailing address

PO BOX 1517
PENDLETON OR
97801-0410
US

V. Phone/Fax

Practice location:
  • Phone: 541-389-7741
  • Fax:
Mailing address:
  • Phone: 877-708-1119
  • Fax: 541-278-8349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11898958-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number208512
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: