Healthcare Provider Details

I. General information

NPI: 1740635531
Provider Name (Legal Business Name): ROBERT ELDER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2016
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2484 RIVER RD
EUGENE OR
97404-2042
US

IV. Provider business mailing address

200 MULLINS DR
LEBANON OR
97355-3983
US

V. Phone/Fax

Practice location:
  • Phone: 541-222-7650
  • Fax: 541-222-7676
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOL60963219
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: