Healthcare Provider Details

I. General information

NPI: 1710167689
Provider Name (Legal Business Name): LAKE OSWEGO DERMATOLOGY GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2007
Last Update Date: 02/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17704 JEAN WAY SUITE 102
LAKE OSWEGO OR
97035-5497
US

IV. Provider business mailing address

17704 JEAN WAY SUITE 102
LAKE OSWEGO OR
97035-5497
US

V. Phone/Fax

Practice location:
  • Phone: 503-635-9221
  • Fax: 503-635-5902
Mailing address:
  • Phone: 503-635-9221
  • Fax: 503-635-5902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: RITA SHIGETA II
Title or Position: OFFICE MANAGER
Credential:
Phone: 503-635-9221