Healthcare Provider Details

I. General information

NPI: 1124075627
Provider Name (Legal Business Name): CORVALLIS GASTROENTEROLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 10/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3521 NW SAMARITAN DR SUITE 101
CORVALLIS OR
97330-4744
US

IV. Provider business mailing address

3521 NW SAMARITAN DR SUITE 101
CORVALLIS OR
97330-4744
US

V. Phone/Fax

Practice location:
  • Phone: 541-768-6119
  • Fax: 541-768-6120
Mailing address:
  • Phone: 541-768-6119
  • Fax: 541-768-6120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateOR

VIII. Authorized Official

Name: SURINDER MOHAN VASDEV
Title or Position: PRESIDENT
Credential: MD
Phone: 541-768-6116