Healthcare Provider Details

I. General information

NPI: 1700851433
Provider Name (Legal Business Name): LAURIE CORDARO D'AVIGNON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 09/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 NE MEDICAL CENTER DR
BEND OR
97701-6051
US

IV. Provider business mailing address

1501 NE MEDICAL CENTER DR
BEND OR
97701-6051
US

V. Phone/Fax

Practice location:
  • Phone: 541-382-2811
  • Fax:
Mailing address:
  • Phone: 541-382-2811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number01055283A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD156715
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberMD156715
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: