Healthcare Provider Details

I. General information

NPI: 1336371517
Provider Name (Legal Business Name): DERYK MARK ZINSER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 10/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36860 INDUSTRIAL WAY
SANDY OR
97055-7371
US

IV. Provider business mailing address

36860 INDUSTRIAL WAY
SANDY OR
97055-7371
US

V. Phone/Fax

Practice location:
  • Phone: 503-826-0206
  • Fax: 503-826-0216
Mailing address:
  • Phone: 503-826-0206
  • Fax: 503-826-0216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO156518
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: