Provider Demographics
NPI:1710167689
Name:LAKE OSWEGO DERMATOLOGY GROUP, PC
Entity Type:Organization
Organization Name:LAKE OSWEGO DERMATOLOGY GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RITA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIGETA
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:503-635-9221
Mailing Address - Street 1:17704 JEAN WAY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-5497
Mailing Address - Country:US
Mailing Address - Phone:503-635-9221
Mailing Address - Fax:503-635-5902
Practice Address - Street 1:17704 JEAN WAY
Practice Address - Street 2:SUITE 102
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5497
Practice Address - Country:US
Practice Address - Phone:503-635-9221
Practice Address - Fax:503-635-5902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty