Provider Demographics
NPI:1639374440
Name:FREDERICK T WALLER MD PC
Entity Type:Organization
Organization Name:FREDERICK T WALLER MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURI
Authorized Official - Middle Name:A
Authorized Official - Last Name:DAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-292-7398
Mailing Address - Street 1:9155 SW BARNES RD STE 211
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6629
Mailing Address - Country:US
Mailing Address - Phone:503-520-1260
Mailing Address - Fax:503-469-9176
Practice Address - Street 1:9155 SW BARNES RD STE 211
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6629
Practice Address - Country:US
Practice Address - Phone:503-520-1260
Practice Address - Fax:503-469-9176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD08927207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORC94020Medicare UPIN