Provider Demographics
NPI:1336294321
Name:DERMATOLOGY AND LASER ASSOCIATES OF MEDFORD
Entity Type:Organization
Organization Name:DERMATOLOGY AND LASER ASSOCIATES OF MEDFORD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:N
Authorized Official - Last Name:NAVERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-773-3636
Mailing Address - Street 1:2959 SISKIYOU BLVD
Mailing Address - Street 2:#B
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8131
Mailing Address - Country:US
Mailing Address - Phone:541-773-3636
Mailing Address - Fax:541-245-9147
Practice Address - Street 1:2959 SISKIYOU BLVD
Practice Address - Street 2:#B
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8131
Practice Address - Country:US
Practice Address - Phone:541-773-3636
Practice Address - Fax:541-245-9147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2017-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287341Medicaid
ORR104891Medicare ID - Type UnspecifiedMEDICARE GROUP #
ORCG3864Medicare PIN