Healthcare Provider Details

I. General information

NPI: 1518067339
Provider Name (Legal Business Name): NATHAN F.E. ULLRICH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 10/13/2021
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 E 19TH ST
THE DALLES OR
97058-3365
US

IV. Provider business mailing address

PO BOX 1520 1805 E. 19TH ST
THE DALLES OR
97058-8003
US

V. Phone/Fax

Practice location:
  • Phone: 541-296-2201
  • Fax: 541-296-1237
Mailing address:
  • Phone: 541-296-2201
  • Fax: 541-296-1237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD00044697
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD154094
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: