Provider Demographics
NPI:1972827913
Name:MAXWELL, KATHRYN LEE (DO)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:LEE
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1066 E 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-3010
Mailing Address - Country:US
Mailing Address - Phone:734-891-7442
Mailing Address - Fax:
Practice Address - Street 1:1426 OAK ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4043
Practice Address - Country:US
Practice Address - Phone:541-431-0000
Practice Address - Fax:541-344-6176
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-19
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60356174207R00000X
ORDO166161207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8921518Medicare PIN
WAG8921519Medicare PIN
WA8921520Medicare PIN