Provider Demographics
NPI:1598962540
Name:WALCZAK, KARIN (MD)
Entity Type:Individual
Prefix:
First Name:KARIN
Middle Name:
Last Name:WALCZAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13370 THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:NEHALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97131-9622
Mailing Address - Country:US
Mailing Address - Phone:503-368-5084
Mailing Address - Fax:503-367-5590
Practice Address - Street 1:230 ROWE ST.
Practice Address - Street 2:
Practice Address - City:WHEELER
Practice Address - State:OR
Practice Address - Zip Code:97147
Practice Address - Country:US
Practice Address - Phone:503-368-5182
Practice Address - Fax:503-368-5590
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15107207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR132862Medicare ID - Type UnspecifiedMEDICARE B
ORC91339Medicare UPIN