Provider Demographics
NPI:1255569273
Name:AANDERUD, PAUL JEFFREY (DO)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:JEFFREY
Last Name:AANDERUD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9775 SE SUNNYSIDE RD STE 500
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-5724
Mailing Address - Country:US
Mailing Address - Phone:503-654-7546
Mailing Address - Fax:503-786-3542
Practice Address - Street 1:9775 SE SUNNYSIDE RD STE 500
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-5724
Practice Address - Country:US
Practice Address - Phone:503-654-7546
Practice Address - Fax:503-786-3542
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-29
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101018458390200000X
ORDO157838207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program