Provider Demographics
NPI:1336307875
Name:CENTRAL OREGON DERMATOLOGY, PC
Entity Type:Organization
Organization Name:CENTRAL OREGON DERMATOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:HANEY
Authorized Official - Suffix:
Authorized Official - Credentials:RHIT
Authorized Official - Phone:541-323-2181
Mailing Address - Street 1:388 SW BLUFF DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1360
Mailing Address - Country:US
Mailing Address - Phone:541-678-0020
Mailing Address - Fax:541-383-2174
Practice Address - Street 1:388 SW BLUFF DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1360
Practice Address - Country:US
Practice Address - Phone:541-678-0020
Practice Address - Fax:541-383-2174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26648261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMD26648OtherLICENSE
OR241835Medicaid
OR1609815166OtherNPI (INDIVIDUAL)
OR1609815166OtherNPI (INDIVIDUAL)
OR156032Medicare UPIN