Healthcare Provider Details

I. General information

NPI: 1003813627
Provider Name (Legal Business Name): PHYLLIS T. DUNCKEL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2005
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 MYRTLE ST
MEDFORD OR
97504-7337
US

IV. Provider business mailing address

1000 E MAIN ST
MEDFORD OR
97504-7667
US

V. Phone/Fax

Practice location:
  • Phone: 541-773-3863
  • Fax: 541-776-2892
Mailing address:
  • Phone: 541-773-3863
  • Fax: 541-776-2892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD166020
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: