Healthcare Provider Details

I. General information

NPI: 1891712477
Provider Name (Legal Business Name): CONNIE SUE DIMARCO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 HARTMAN LN
SPRINGFIELD OR
97477-1118
US

IV. Provider business mailing address

2400 HARTMAN LN
SPRINGFIELD OR
97477-1118
US

V. Phone/Fax

Practice location:
  • Phone: 541-334-3350
  • Fax: 541-284-5198
Mailing address:
  • Phone: 541-334-3350
  • Fax: 541-284-5198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberMD26368
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: