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General NPI Number Information
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NPI Number | 1215035332
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Entity Type | Organization
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Legal Business Name | ADVANCED DERMATOLOGY OF OREGON PC
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Dates
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Enumeration Date | 09/20/2006
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Last Update Date | 08/27/2014
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Provider Practice Location Address
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Address Line | 19255 SW 65TH AVE STE 260
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City | TUALATIN
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State | OR
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Zip | 97062-7451
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Country | US
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Telephone | 503-692-9525
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Fax | 503-692-8643
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Provider Business Mailing Address
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Address Line | 19255 SW 65TH AVE STE 260
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City | TUALATIN
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State | OR
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Zip | 97062-7451
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Country | US
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Telephone | 503-692-9525
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Fax | 503-692-8643
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Authorized Official
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Title or Position | OWNER
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Name | MAERAN LANDERS
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Credential | M.D.
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Telephone | 503-692-9525
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 338484-90
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License Number State | OR
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