Provider Demographics
NPI:1689659377
Name:CHERRY, UNKNOWN (MD)
Entity Type:Individual
Prefix:DR
First Name:UNKNOWN
Middle Name:
Last Name:CHERRY
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 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-0000
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-267-3800
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-0000
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:541-267-3800
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24238207RH0003X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286215Medicaid
OR830008657OtherRAILROAD PROVIDER NUMBER
OR9940385OtherNAME VERIFICATION - OREGON DRIVERS LICENSE-CHERRY HAS NO LAST NAME
OR1407812365OtherGROUP NPI NUMBER
ORCB3544OtherTRAV RR MED GROUP NUMBER
OR930635514OtherGROUP TAX ID FOR BILLING
ORMD24238OtherMEDICAL LICENSE OREGON
ORR0000WFBTVOtherGROUP PIN NUMBER
ORR0000WFBTVOtherGROUP PIN NUMBER
OR830008657OtherRAILROAD PROVIDER NUMBER
OR0577260001Medicare NSC