Provider Demographics
NPI:1700221397
Name:CLACKAMAS DERMATOLOGY PC
Entity Type:Organization
Organization Name:CLACKAMAS DERMATOLOGY PC
Other - Org Name:GOODSKIN DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:JEFFERY
Authorized Official - Last Name:ANDERUD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:503-654-7546
Mailing Address - Street 1:12605 SE 97TH AVE
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-9706
Mailing Address - Country:US
Mailing Address - Phone:503-654-7546
Mailing Address - Fax:503-786-3542
Practice Address - Street 1:12605 SE 97TH AVE
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9706
Practice Address - Country:US
Practice Address - Phone:503-654-7546
Practice Address - Fax:503-786-3542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-08
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO157838207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500702253Medicaid