Provider Demographics
NPI:1265463996
Name:FELLIN, SAMUEL J (DO)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:J
Last Name:FELLIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:12442 SW SCHOLLS FERRY RD
Practice Address - Street 2:SUITE 106
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-3396
Practice Address - Country:US
Practice Address - Phone:503-216-9200
Practice Address - Fax:503-212-6922
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORDO16616207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR110101988OtherRR MEDICARE
F64396Medicare UPIN