Healthcare Provider Details

I. General information

NPI: 1841372059
Provider Name (Legal Business Name): THEODORE DOUGLAS FLAIZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: T D FLAIZ M.D.

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 03/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 NW 11TH ST SUITE E-15
HERMISTON OR
97838-8602
US

IV. Provider business mailing address

600 NW 11TH ST STE E15
HERMISTON OR
97838-8602
US

V. Phone/Fax

Practice location:
  • Phone: 541-567-6434
  • Fax: 541-567-6019
Mailing address:
  • Phone: 541-567-6434
  • Fax: 541-567-6019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD08491
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: