Healthcare Provider Details

I. General information

NPI: 1396849857
Provider Name (Legal Business Name): CONSULTANTS IN DERMATOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 02/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 E 12TH ST
THE DALLES OR
97058-3137
US

IV. Provider business mailing address

PO BOX 1044
THE DALLES OR
97058-9044
US

V. Phone/Fax

Practice location:
  • Phone: 541-506-6930
  • Fax: 541-506-6931
Mailing address:
  • Phone: 541-296-7548
  • Fax: 541-296-7619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH E ROBERTSON JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 503-494-8033