MEDICARE: DONALD DRAVIS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084F0202X	Forensic Psychiatry Physician	MD21645	OR

General Provider Information

NPI Number	:	1215142294
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONALD DRAVIS M.D.

Provider Business Mailing Address
First Line	:	COUNSELING AND TREATMENT SERVICES
Second Line	:	2575 CENTER STREET NE
City	:	SALEM
State	:	OR
Zip	:	97310-0001
Country	:	US
Telephone Number	:	503-378-2446
Fax Number	:	503-378-3228

Provider Business Practice Location Address
First Line	:	OREGON STATE PENITENTIARY
Second Line	:	2605 STATE STREET
City	:	SALEM
State	:	OR
Zip	:	97310-0001
Country	:	US
Telephone Number	:	503-378-2446
Fax Number	:	503-378-3228

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/11/2007
Last Update Date	:	07/08/2007

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