Healthcare Provider Details

I. General information

NPI: 1851884506
Provider Name (Legal Business Name): DANIEL EBERT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2018
Last Update Date: 09/16/2022
Certification Date: 09/16/2022
Deactivation Date: 04/03/2019
Reactivation Date: 05/01/2019

III. Provider practice location address

5234 SW PHILOMATH BLVD
CORVALLIS OR
97333-1042
US

IV. Provider business mailing address

PO BOX 1189
CORVALLIS OR
97339-1189
US

V. Phone/Fax

Practice location:
  • Phone: 541-768-4970
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPG194181
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: