Provider Demographics
NPI:1700033677
Name:OVERHOLSER, ANNMARIE CC (MD)
Entity Type:Individual
Prefix:MS
First Name:ANNMARIE
Middle Name:CC
Last Name:OVERHOLSER
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:PO BOX 568
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:OR
Mailing Address - Zip Code:97113-0568
Mailing Address - Country:US
Mailing Address - Phone:503-352-8657
Mailing Address - Fax:503-352-8658
Practice Address - Street 1:2251 E HANCOCK ST
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-2145
Practice Address - Country:US
Practice Address - Phone:971-281-3000
Practice Address - Fax:503-357-4371
Is Sole Proprietor?:No
Enumeration Date:2008-08-22
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLL17910207Q00000X
ORMD155418207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500636504Medicaid
OR500636504Medicaid