Provider Demographics
NPI:1487614509
Name:MCNABB, EARL DEAN (DPM)
Entity type:Individual
Prefix:DR
First Name:EARL
Middle Name:DEAN
Last Name:MCNABB
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:503-390-1184
Practice Address - Street 1:3625 RIVER RD N
Practice Address - Street 2:#275
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-5977
Practice Address - Country:US
Practice Address - Phone:503-390-0959
Practice Address - Fax:503-390-1184
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00344213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR133628OtherMEDICARE KEIZER OFFICE
ORR118188OtherMEDICARE MAC OFFICE
OR182958Medicaid
ORR133628OtherMEDICARE KEIZER OFFICE