Provider Demographics
NPI:1003813627
Name:DUNCKEL, PHYLLIS T (MD)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:T
Last Name:DUNCKEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7667
Mailing Address - Country:US
Mailing Address - Phone:541-773-3863
Mailing Address - Fax:541-776-2892
Practice Address - Street 1:19 MYRTLE ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7337
Practice Address - Country:US
Practice Address - Phone:541-773-3863
Practice Address - Fax:541-776-2892
Is Sole Proprietor?:No
Enumeration Date:2005-06-29
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD166020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR22959Medicaid
OR181804Medicaid
OR096511Medicaid
WA8155269Medicaid
080193873OtherRR MEDICARE
WA166058OtherLABOR & IND.
WA8934158OtherCRIME VICTIMS
75784Medicare UPIN
WA8155269Medicaid
OR181804Medicaid