Healthcare Provider Details

I. General information

NPI: 1053495630
Provider Name (Legal Business Name): DIANA MARIE LINDEROTH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 11/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 PROGRESS WAY
WOODBURN OR
97071-9764
US

IV. Provider business mailing address

2050 PROGRESS WAY
WOODBURN OR
97071-9764
US

V. Phone/Fax

Practice location:
  • Phone: 503-981-5348
  • Fax: 503-981-0423
Mailing address:
  • Phone: 503-981-5348
  • Fax: 503-981-0423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD26022
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM-2009
License Number StateGU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: