Provider Demographics
NPI:1710208962
Name:THOMAS D UTTERBACK, MD, PC
Entity Type:Organization
Organization Name:THOMAS D UTTERBACK, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:UTTERBACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-236-2400
Mailing Address - Street 1:PO BOX 942
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-0942
Mailing Address - Country:US
Mailing Address - Phone:503-263-2400
Mailing Address - Fax:
Practice Address - Street 1:8051 S LONE ELDER RD
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-9127
Practice Address - Country:US
Practice Address - Phone:503-263-2400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-22
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD07612174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000BHTPZMedicare PIN
ORC93989Medicare UPIN