Provider Demographics
NPI:1093786261
Name:VAN DIS, FREDERIC J (MD)
Entity Type:Individual
Prefix:
First Name:FREDERIC
Middle Name:J
Last Name:VAN DIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 NW MEDICAL LOOP STE 190
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-8835
Mailing Address - Country:US
Mailing Address - Phone:541-677-4319
Mailing Address - Fax:541-677-2294
Practice Address - Street 1:2801 NW MERCY DR
Practice Address - Street 2:STE. 300
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471
Practice Address - Country:US
Practice Address - Phone:541-677-1555
Practice Address - Fax:541-677-6543
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD12356207RC0000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR060070869OtherRAILROAD MEDICARE
ORMD12356OtherLICENSE
OR114173Medicaid
R176256OtherPTAN