Provider Demographics
NPI:1508974932
Name:RUNCKEL, DOUGLAS NEWELL (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:NEWELL
Last Name:RUNCKEL
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 1:3419 PRINGLE RD SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-2649
Mailing Address - Country:US
Mailing Address - Phone:503-370-8988
Mailing Address - Fax:503-258-6864
Practice Address - Street 1:13705 NE AIRPORT WAY STE C
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-1048
Practice Address - Country:US
Practice Address - Phone:503-258-6846
Practice Address - Fax:503-258-6864
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR MD09235207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology