Provider Demographics
NPI:1437278298
Name:DODEN, MICHAEL J (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:DODEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:MIKE
Other - Middle Name:
Other - Last Name:DODEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:805 SW INDUSTRIAL WAY
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1093
Mailing Address - Country:US
Mailing Address - Phone:541-585-2529
Mailing Address - Fax:541-585-2536
Practice Address - Street 1:1303 NE CUSHING DR
Practice Address - Street 2:SUITE 150
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3891
Practice Address - Country:US
Practice Address - Phone:541-382-7875
Practice Address - Fax:541-382-2181
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3782225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR182250Medicaid
ORR147041Medicare PIN