Healthcare Provider Details

I. General information

NPI: 1922365956
Provider Name (Legal Business Name): DERMATOLOGY NORTHWEST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2012
Last Update Date: 04/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 INLAND SHORES WAY N STE 202
KEIZER OR
97303-3883
US

IV. Provider business mailing address

5900 INLAND SHORES WAY STE 202
KEIZER OR
97303
US

V. Phone/Fax

Practice location:
  • Phone: 503-463-6799
  • Fax: 503-463-6771
Mailing address:
  • Phone: 503-463-6799
  • Fax: 503-463-6771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD10836
License Number StateOR

VIII. Authorized Official

Name: TERI L LITKE
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 503-463-6799