Provider Demographics
NPI:1255329728
Name:DAUTERMAN, KENT W (MD)
Entity type:Individual
Prefix:
First Name:KENT
Middle Name:W
Last Name:DAUTERMAN
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 1:520 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4314
Mailing Address - Country:US
Mailing Address - Phone:541-282-6606
Mailing Address - Fax:541-282-6601
Practice Address - Street 1:520 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 200
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-4314
Practice Address - Country:US
Practice Address - Phone:541-282-6600
Practice Address - Fax:541-282-6601
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24049207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227698Medicaid
OR226915Medicaid
G49023Medicare UPIN