Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | 15-00002769 | OR |
NPI | 1558719369 |
---|---|
Provider Name | Douglas Vangordon |
First Address | Bend, OR 97701-4283 |
Second Address | Bend, OR 97703-7195 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/06/2016 |
Last Update Date | 02/06/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
134170 | (05) | OR |