Provider Demographics
NPI:1952424541
Name:DONALD E. WONDERLY MD PC
Entity Type:Organization
Organization Name:DONALD E. WONDERLY MD PC
Other - Org Name:ACCENT ON WOMEN'S HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:A
Authorized Official - Last Name:PEACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-677-4427
Mailing Address - Street 1:PO BOX 568
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:OR
Mailing Address - Zip Code:97495-0568
Mailing Address - Country:US
Mailing Address - Phone:541-677-4427
Mailing Address - Fax:541-677-6522
Practice Address - Street 1:2460 NW STEWART PKWY
Practice Address - Street 2:SUITE 240
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-1516
Practice Address - Country:US
Practice Address - Phone:541-677-4427
Practice Address - Fax:541-677-6522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22082207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR028442Medicaid
ORR113593Medicare PIN