Provider Demographics
NPI:1689755175
Name:UNDERWOOD, FRED LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:LEE
Last Name:UNDERWOOD
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 1:9340 SW BARNES RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6623
Mailing Address - Country:US
Mailing Address - Phone:503-297-6334
Mailing Address - Fax:503-297-2360
Practice Address - Street 1:10150 SE 32ND AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-6516
Practice Address - Country:US
Practice Address - Phone:503-297-6334
Practice Address - Fax:503-297-2360
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD09581207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR234732Medicaid
ORD86844Medicare UPIN
OR234732Medicaid