Provider Demographics
NPI:1679869119
Name:AUSTAD, STEPHEN SPENCER (DO)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:SPENCER
Last Name:AUSTAD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 E 19TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3385
Mailing Address - Country:US
Mailing Address - Phone:801-644-6019
Mailing Address - Fax:
Practice Address - Street 1:123 C AVE
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-2353
Practice Address - Country:US
Practice Address - Phone:541-316-6575
Practice Address - Fax:541-210-8913
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE942208D00000X
390200000X
CA20A17149207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program