Healthcare Provider Details

I. General information

NPI: 1316944572
Provider Name (Legal Business Name): ANTHONY CHARLIES DE MORY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2005
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date: 03/20/2006
Reactivation Date: 05/25/2006

III. Provider practice location address

3355 RIVERBEND DR STE 200
SPRINGFIELD OR
97477-8800
US

IV. Provider business mailing address

3355 RIVERBEND DR STE 200
SPRINGFIELD OR
97477-8800
US

V. Phone/Fax

Practice location:
  • Phone: 541-485-6478
  • Fax: 541-868-9606
Mailing address:
  • Phone: 541-485-6478
  • Fax: 541-868-9606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberM4027
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMD161523
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: