Healthcare Provider Details

I. General information

NPI: 1295716926
Provider Name (Legal Business Name): DIEGO JOHN MUILENBURG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 02/28/2024
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PEACEHEALTH SURGICAL SPECIALITIES 3355 RIVERBEND DR., SUITE 300
SPRINGFIELD OR
97477-8800
US

IV. Provider business mailing address

PEACEHEALTH SURGICAL SPECIALITIES 3355 RIVERBEND DR., SUITE 300
SPRINGFIELD OR
97477-8800
US

V. Phone/Fax

Practice location:
  • Phone: 541-222-8333
  • Fax: 541-222-8320
Mailing address:
  • Phone: 541-222-8333
  • Fax: 541-222-8320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number53543
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberMD166758
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD166758
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: