Healthcare Provider Details

I. General information

NPI: 1588001895
Provider Name (Legal Business Name): WADIH CHAKKOUR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2013
Last Update Date: 02/07/2022
Certification Date: 02/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3355 RIVERBEND DR STE 240
SPRINGFIELD OR
97477-8800
US

IV. Provider business mailing address

3355 RIVERBEND DR STE 240
SPRINGFIELD OR
97477-8800
US

V. Phone/Fax

Practice location:
  • Phone: 554-168-7171
  • Fax: 541-687-7943
Mailing address:
  • Phone: 541-868-9292
  • Fax: 541-687-7943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberMD196187
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberMD61241315
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberMD61241315
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberMD196187
License Number StateOR
# 5
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberMD61241315
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: