Healthcare Provider Details

I. General information

NPI: 1457001398
Provider Name (Legal Business Name): SOREN KOSTOFF MADSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2022
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 SUNSET DR STE E
LA GRANDE OR
97850-1200
US

IV. Provider business mailing address

10902 S D ST
LA GRANDE OR
97850-8434
US

V. Phone/Fax

Practice location:
  • Phone: 541-663-3150
  • Fax: 541-975-5111
Mailing address:
  • Phone: 541-963-1967
  • Fax: 541-963-1837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberDO229452
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: