Provider Demographics
NPI:1598826851
Name:ELMGREN, DAVID T (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:T
Last Name:ELMGREN
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 1:2973 12TH STREET SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-6162
Mailing Address - Country:US
Mailing Address - Phone:503-561-7100
Mailing Address - Fax:503-561-7124
Practice Address - Street 1:2973 12TH STREET SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-6162
Practice Address - Country:US
Practice Address - Phone:503-561-7100
Practice Address - Fax:503-561-7124
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD07578208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR234658Medicaid
ORD73020Medicare UPIN
OR234658Medicaid