Basic Information
Provider Information | |||||||||
NPI: | 1326299843 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HAMBLIN | ||||||||
FirstName: | DOUGLAS | ||||||||
MiddleName: | SCOTT | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 278 | ||||||||
Address2: |   | ||||||||
City: | WOODBURN | ||||||||
State: | OR | ||||||||
PostalCode: | 970710278 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9719835260 | ||||||||
FaxNumber: | 9719835326 | ||||||||
Practice Location | |||||||||
Address1: | 5685 INLAND SHORES WAY | ||||||||
Address2: |   | ||||||||
City: | KEIZER | ||||||||
State: | OR | ||||||||
PostalCode: | 97303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5037792271 | ||||||||
FaxNumber: | 5037792272 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/02/2008 | ||||||||
LastUpdateDate: | 05/23/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME104220 | FL | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208M00000X | 104220 | FL | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 208000000X | MD167314 | OR | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | BY092Z | 01 | FL | MEDICARE PTAN | OTHER | 001217400 | 05 | FL |   | MEDICAID |