Healthcare Provider Details

I. General information

NPI: 1164319208
Provider Name (Legal Business Name): DONAVAN J SALSBURY CRM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DONAVAN J VAIT

II. Dates (important events)

Enumeration Date: 06/20/2025
Last Update Date: 06/20/2025
Certification Date: 06/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21440 SE STARK ST
GRESHAM OR
97030-2024
US

IV. Provider business mailing address

11010 SE DIVISION ST STE 11104SE
PORTLAND OR
97266-6400
US

V. Phone/Fax

Practice location:
  • Phone: 971-703-4623
  • Fax:
Mailing address:
  • Phone: 971-703-4623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number3715820
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: