Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207RR0500X | Rheumatology | 56254 | CO |
Y | 207RR0500X | Rheumatology | MD153128 | OR |
NPI | 1104016278 |
---|---|
Provider Name | Dominik Grzegorz Sokalski |
First Address | Medford, OR 97504-5207 |
Second Address | Medford, OR 97504-5207 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/07/2007 |
Last Update Date | 11/02/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
478052ZL1P | MEDICARE CO (01) | CO |
500722930 | (05) | OR |
DR.0056254 | STATE LICENSE (01) | CO |
MD153128 | STATE LICENSE (01) | OR |
R194430 | MEDICARE OR (01) | OR |