Healthcare Provider Details

I. General information

NPI: 1841294774
Provider Name (Legal Business Name): DOUGLAS EDWARD ANDERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 NW MERCY DR STE 300
ROSEBURG OR
97471-2348
US

IV. Provider business mailing address

201 NW MEDICAL LOOP STE 190
ROSEBURG OR
97471-8835
US

V. Phone/Fax

Practice location:
  • Phone: 541-677-1555
  • Fax: 541-677-2113
Mailing address:
  • Phone: 541-677-4319
  • Fax: 541-677-2294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD192562
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: