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General NPI Number Information
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NPI Number | 1548689318
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Entity Type | Individual
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Provider Name | JP PROUTY M.D.
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Gender | Male
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Dates
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Enumeration Date | 04/09/2014
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Last Update Date | 09/13/2017
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Provider Practice Location Address
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Address Line | 2801 DAGGETT AVE
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City | KLAMATH FALLS
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State | OR
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Zip | 97601-7150
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Country | US
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Telephone | 541-274-4510
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Fax |
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Provider Business Mailing Address
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Address Line | 3181 SW SAM JACKSON PARK RD
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City | PORTLAND
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State | OR
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Zip | 97239-3011
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Country | US
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Telephone | 503-494-8211
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | M-13859
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License Number State | ID
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