Healthcare Provider Details

I. General information

NPI: 1912271735
Provider Name (Legal Business Name): JOHN ARTHUR ENBOM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2012
Last Update Date: 02/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2625 SW BROOKLANE DR
CORVALLIS OR
97333-1513
US

IV. Provider business mailing address

2625 SW BROOKLANE DR
CORVALLIS OR
97333-1513
US

V. Phone/Fax

Practice location:
  • Phone: 541-757-9614
  • Fax: 541-752-7030
Mailing address:
  • Phone: 541-757-9614
  • Fax: 541-752-7030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VC0200X
TaxonomyCritical Care Medicine (Obstetrics & Gynecology) Physician
License NumberMD07110
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: