Provider Demographics
NPI:1104841642
Name:HARDIN, WALTER RAY (DO)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:RAY
Last Name:HARDIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23820 NW TURNER CREEK RD
Mailing Address - Street 2:
Mailing Address - City:YAMHILL
Mailing Address - State:OR
Mailing Address - Zip Code:97148-8217
Mailing Address - Country:US
Mailing Address - Phone:503-662-5190
Mailing Address - Fax:
Practice Address - Street 1:6 CENTERPOINTE DR STE 200
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-8660
Practice Address - Country:US
Practice Address - Phone:503-797-2268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO12722207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR235200Medicaid
ORC21954Medicare UPIN
OR08WCBCCBMedicare ID - Type Unspecified