Provider Demographics
NPI:1689985830
Name:CHADWICK, PRESTON WYATT (MD)
Entity Type:Individual
Prefix:DR
First Name:PRESTON
Middle Name:WYATT
Last Name:CHADWICK
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 1:2441 GREAR ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-2749
Mailing Address - Country:US
Mailing Address - Phone:503-364-3321
Mailing Address - Fax:
Practice Address - Street 1:2441 GREAR ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2749
Practice Address - Country:US
Practice Address - Phone:503-364-3321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09197800207N00000X
ORMD166983207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology