MEDICARE: THOMAS DONALD WYNNE 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	2085R0001X	Radiation Oncology Physician	MD19191	OR
2	2085R0203X	Therapeutic Radiology Physician	MD19191	OR

General Provider Information

NPI Number	:	1417945106
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS DONALD WYNNE M.D.

Provider Business Mailing Address
First Line	:	3620 N INTERSTATE AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97227-1106
Country	:	US
Telephone Number	:	503-280-2931
Fax Number	:	503-280-2938

Provider Business Practice Location Address
First Line	:	3620 N INTERSTATE AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97227-1106
Country	:	US
Telephone Number	:	503-280-2931
Fax Number	:	503-280-2938

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

Provider Enumeration Date	:	10/07/2005
Last Update Date	:	02/04/2022

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