Healthcare Provider Details

I. General information

NPI: 1609851898
Provider Name (Legal Business Name): GERALD ENGSTROM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 10/13/2021
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 NW EDENBOWER BLVD STE 112
ROSEBURG OR
97471
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 541-464-6260
  • Fax: 541-229-0014
Mailing address:
  • Phone: 541-677-4319
  • Fax: 541-677-2294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: