Provider Demographics
NPI:1063690527
Name:DEAN MCNABB DPM LLC
Entity type:Organization
Organization Name:DEAN MCNABB DPM LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EARL
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:MCNABB
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:503-390-0959
Mailing Address - Street 1:PO BOX 20367
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97307-0367
Mailing Address - Country:US
Mailing Address - Phone:503-390-0959
Mailing Address - Fax:877-878-1984
Practice Address - Street 1:851 NE BAKER ST
Practice Address - Street 2:SUITE 4
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-4991
Practice Address - Country:US
Practice Address - Phone:503-434-5222
Practice Address - Fax:877-878-1984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00344213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR182958Medicaid
OR118186OtherMEDICARE MAC
OR118186OtherMEDICARE MAC
ORU91057Medicare UPIN