Provider Demographics
NPI:1508892605
Name:ABBOTT, DOUGLAS D (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:D
Last Name:ABBOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2265 EXCHANGE ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-3331
Mailing Address - Country:US
Mailing Address - Phone:503-338-4075
Mailing Address - Fax:503-338-4076
Practice Address - Street 1:2265 EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3331
Practice Address - Country:US
Practice Address - Phone:503-338-4075
Practice Address - Fax:503-338-4076
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD150601207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORH50980Medicare UPIN
OR00A648691Medicare PIN