Provider Demographics
NPI:1699966689
Name:DOVE, PHILLIP M
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:M
Last Name:DOVE
Suffix:
Gender:M
Credentials:
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 3300
Mailing Address - Street 2:
Mailing Address - City:LA PINE
Mailing Address - State:OR
Mailing Address - Zip Code:97739-3300
Mailing Address - Country:US
Mailing Address - Phone:541-536-3435
Mailing Address - Fax:541-536-8047
Practice Address - Street 1:51600 HUNTINGTON RD
Practice Address - Street 2:
Practice Address - City:LA PINE
Practice Address - State:OR
Practice Address - Zip Code:97739-9626
Practice Address - Country:US
Practice Address - Phone:541-536-3435
Practice Address - Fax:541-536-8047
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60152937207R00000X
ORMD157489207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500645438Medicaid
WA2008096Medicaid
WAG8892632OtherPTAN
WA2008096Medicaid