Healthcare Provider Details

I. General information

NPI: 1154313682
Provider Name (Legal Business Name): RONALD WAYNE POWELL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 06/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1673 10TH ST.
WEST LINN OR
97068-4607
US

IV. Provider business mailing address

1673 10TH ST.
WEST LINN OR
97068-4607
US

V. Phone/Fax

Practice location:
  • Phone: 503-657-3158
  • Fax: 503-657-4579
Mailing address:
  • Phone: 503-657-3158
  • Fax: 503-657-4579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO11790
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: