Provider Demographics
NPI:1215035332
Name:ADVANCED DERMATOLOGY OF OREGON PC
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGY OF OREGON PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAERAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-692-9525
Mailing Address - Street 1:19255 SW 65TH AVE
Mailing Address - Street 2:STE 260
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-7451
Mailing Address - Country:US
Mailing Address - Phone:503-692-9525
Mailing Address - Fax:503-692-8643
Practice Address - Street 1:19255 SW 65TH AVE
Practice Address - Street 2:STE 260
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7451
Practice Address - Country:US
Practice Address - Phone:503-692-9525
Practice Address - Fax:503-692-8643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR338484-90207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR135645Medicare PIN