=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710167689
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE OSWEGO DERMATOLOGY GROUP, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2007
-----------------------------------------------------
Last Update Date | 02/03/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17704 JEAN WAY SUITE 102
-----------------------------------------------------
City | LAKE OSWEGO
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97035-5497
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-635-9221
-----------------------------------------------------
Fax | 503-635-5902
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17704 JEAN WAY SUITE 102
-----------------------------------------------------
City | LAKE OSWEGO
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97035-5497
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-635-9221
-----------------------------------------------------
Fax | 503-635-5902
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | RITA SHIGETA II
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 503-635-9221
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------