Provider Demographics
NPI:1841372059
Name:FLAIZ, THEODORE DOUGLAS (MD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:DOUGLAS
Last Name:FLAIZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:T
Other - Middle Name:D
Other - Last Name:FLAIZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:600 NW 11TH ST
Mailing Address - Street 2:STE E15
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-8602
Mailing Address - Country:US
Mailing Address - Phone:541-567-6434
Mailing Address - Fax:541-567-6019
Practice Address - Street 1:600 NW 11TH ST
Practice Address - Street 2:SUITE E-15
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-8602
Practice Address - Country:US
Practice Address - Phone:541-567-6434
Practice Address - Fax:541-567-6019
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD08491207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR234401Medicaid
OR234401Medicaid
ORR08WCBCKDMedicare PIN