Provider Demographics
NPI:1710931274
Name:PONDEROSA MEDICAL
Entity Type:Organization
Organization Name:PONDEROSA MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GILBERT
Authorized Official - Middle Name:B
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-312-8679
Mailing Address - Street 1:1558 SW NANCY WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3216
Mailing Address - Country:US
Mailing Address - Phone:541-312-8679
Mailing Address - Fax:
Practice Address - Street 1:1558 SW NANCY WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3216
Practice Address - Country:US
Practice Address - Phone:541-312-8679
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD12002207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORC91059Medicare UPIN
OR104749Medicare ID - Type Unspecified
OR130669Medicare ID - Type Unspecified
ORC93124Medicare UPIN