Provider Demographics
NPI:1184696676
Name:VANVOLKINBURG, EARL J (MD)
Entity type:Individual
Prefix:
First Name:EARL
Middle Name:J
Last Name:VANVOLKINBURG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2478 13TH ST SE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-2546
Mailing Address - Country:US
Mailing Address - Phone:503-588-5892
Mailing Address - Fax:503-485-0709
Practice Address - Street 1:2478 13TH ST SE
Practice Address - Street 2:SUITE 200
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-2546
Practice Address - Country:US
Practice Address - Phone:503-588-5892
Practice Address - Fax:503-485-0709
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR09149207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR207126Medicaid
ORC94000Medicare UPIN
OR207126Medicaid