Provider Demographics
NPI:1205838091
Name:DAWLEY, DOUGLAS LEE (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:LEE
Last Name:DAWLEY
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 1:10000 SE MAIN ST STE 60
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2474
Mailing Address - Country:US
Mailing Address - Phone:503-257-0959
Mailing Address - Fax:503-257-3457
Practice Address - Street 1:10000 SE MAIN ST
Practice Address - Street 2:SUITE 60
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2448
Practice Address - Country:US
Practice Address - Phone:503-257-0959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD14940207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR101071Medicaid
WA1015486Medicaid
OR157735Medicare PIN
OR06WCBBPAMedicare ID - Type Unspecified
OR101071Medicaid