Healthcare Provider Details

I. General information

NPI: 1316122708
Provider Name (Legal Business Name): GERALD ENGSTROM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2008
Last Update Date: 01/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1813 W HARVARD AVE STE 427
ROSEBURG OR
97470-8712
US

IV. Provider business mailing address

1813 W HARVARD AVE STE 427
ROSEBURG OR
97470-8712
US

V. Phone/Fax

Practice location:
  • Phone: 541-673-3447
  • Fax: 541-677-9712
Mailing address:
  • Phone: 541-673-3447
  • Fax: 541-677-9712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD15315
License Number StateOR

VIII. Authorized Official

Name: GERALD W ENGSTROM
Title or Position: OWNER
Credential: M.D.
Phone: 541-673-3447