Provider Demographics
NPI:1346213832
Name:RICHARD W. PEFFLEY, DPM, A
Entity Type:Organization
Organization Name:RICHARD W. PEFFLEY, DPM, A
Other - Org Name:SALEM FOOT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:PEFFLEY
Authorized Official - Suffix:II
Authorized Official - Credentials:DPM
Authorized Official - Phone:503-370-8784
Mailing Address - Street 1:350 MILLER ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4248
Mailing Address - Country:US
Mailing Address - Phone:503-370-8784
Mailing Address - Fax:503-362-4017
Practice Address - Street 1:350 MILLER ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4248
Practice Address - Country:US
Practice Address - Phone:503-370-8784
Practice Address - Fax:503-362-4017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00219213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR065941Medicaid
OR065941Medicaid
OR1148590001Medicare NSC