Provider Demographics
NPI:1871574947
Name:MAEYENS, EDGAR (MD)
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:
Last Name:MAEYENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1793 13TH ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-2541
Mailing Address - Country:US
Mailing Address - Phone:503-362-8385
Mailing Address - Fax:503-362-8435
Practice Address - Street 1:375 PARK AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2242
Practice Address - Country:US
Practice Address - Phone:541-267-7543
Practice Address - Fax:541-267-2076
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD08528207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORC93204Medicare UPIN