Healthcare Provider Details

I. General information

NPI: 1356385512
Provider Name (Legal Business Name): ROBERT MICHAEL JEPSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 SE COURT AVE
PENDLETON OR
97801-3217
US

IV. Provider business mailing address

3018 FRUITVALE ROAD
COUNCIL ID
83612
US

V. Phone/Fax

Practice location:
  • Phone: 541-276-5121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD24986
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: