Provider Demographics
NPI:1861479396
Name:DACKER, EVELIN (MD)
Entity Type:Individual
Prefix:DR
First Name:EVELIN
Middle Name:
Last Name:DACKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 883
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97308-0883
Mailing Address - Country:US
Mailing Address - Phone:503-399-1400
Mailing Address - Fax:503-399-1406
Practice Address - Street 1:374 OWENS ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4145
Practice Address - Country:US
Practice Address - Phone:503-399-1400
Practice Address - Fax:503-399-1406
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD20032207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
132646OtherMEDICARE- DR DACKER INDIV
OR082073OtherOMAP
ORMD20032OtherSTATE MEDICAL LICENSE
OR308690OtherPROVIDENCE
ORMD20032OtherSTATE MEDICAL LICENSE
OR838541001OtherBLUECROSS BLUESHIELD
OR082073OtherOMAP
G06671Medicare UPIN
OR5005267001OtherFIRSTCHOICE 65
ORM1139 01OtherPACIFICSOURCE