Provider Demographics
NPI:1831136829
Name:UNDERWOOD, WILLIE III (MD)
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:
Last Name:UNDERWOOD
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1517
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-0410
Mailing Address - Country:US
Mailing Address - Phone:877-708-1119
Mailing Address - Fax:541-278-8349
Practice Address - Street 1:1247 NE MEDICAL CENTER DR STE C
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3786
Practice Address - Country:US
Practice Address - Phone:541-322-5753
Practice Address - Fax:541-278-8368
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY250131208800000X
ORMD214003208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03038759Medicaid
NYJ400000399Medicare PIN