Provider Demographics
NPI:1245221084
Name:WILLAMETTE DERMATOLOGY, P.C.
Entity Type:Organization
Organization Name:WILLAMETTE DERMATOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:A
Authorized Official - Last Name:KLAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-691-1743
Mailing Address - Street 1:PO BOX 23200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97281-3200
Mailing Address - Country:US
Mailing Address - Phone:503-691-1743
Mailing Address - Fax:503-691-0983
Practice Address - Street 1:19875 SW 65TH AVE
Practice Address - Street 2:SUITE 260
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-8353
Practice Address - Country:US
Practice Address - Phone:503-691-1743
Practice Address - Fax:503-691-0983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-01
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21432174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORDG7086OtherRAILROAD MEDICARE
OR151278Medicaid
OR1508999152OtherINDIVIDUAL PROVIDER NPI
ORR104407Medicare PIN
OR1508999152OtherINDIVIDUAL PROVIDER NPI