Healthcare Provider Details

I. General information

NPI: 1972506087
Provider Name (Legal Business Name): PHILIP PADEN EYE CARE CENTER M D
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 01/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 STEWART AVE SUITE 110
MEDFORD OR
97501
US

IV. Provider business mailing address

221 STEWART AVE SUITE 110
MEDFORD OR
97501
US

V. Phone/Fax

Practice location:
  • Phone: 541-776-9026
  • Fax: 541-776-9096
Mailing address:
  • Phone: 541-776-9026
  • Fax: 541-776-9096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number13653
License Number StateOR

VIII. Authorized Official

Name: PHILIP Y PADEN
Title or Position: OWNER/PHYSICIAN
Credential: M.D.
Phone: 541-776-9026