Provider Demographics
NPI:1154313682
Name:POWELL, RONALD WAYNE (DO)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:WAYNE
Last Name:POWELL
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 1:1673 10TH ST.
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-4607
Mailing Address - Country:US
Mailing Address - Phone:503-657-3158
Mailing Address - Fax:503-657-4579
Practice Address - Street 1:1673 10TH ST.
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-4607
Practice Address - Country:US
Practice Address - Phone:503-657-3158
Practice Address - Fax:503-657-4579
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO11790207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR218545Medicaid
OR218545Medicaid
OR114203Medicare ID - Type UnspecifiedMEDICARE