Provider Demographics
NPI:1770561607
Name:LIVERMORE, DOUG S (MD)
Entity type:Individual
Prefix:
First Name:DOUG
Middle Name:S
Last Name:LIVERMORE
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:PO BOX 1648
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97440-1648
Mailing Address - Country:US
Mailing Address - Phone:541-686-9000
Mailing Address - Fax:541-242-4585
Practice Address - Street 1:2830 CRESCENT AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97408-7397
Practice Address - Country:US
Practice Address - Phone:541-686-9000
Practice Address - Fax:541-242-4585
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10041208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR111575Medicaid
OR111575Medicaid
C93164Medicare UPIN