Basic Information
| Provider Information | |||||||||
| NPI: | 1558312835 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAILEY | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | ALLAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3375 SW TERWILLIGER BLVD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972394146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034943000 | ||||||||
| FaxNumber: | 5034944286 | ||||||||
| Practice Location | |||||||||
| Address1: | 3375 SW TERWILLIGER BLVD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034943000 | ||||||||
| FaxNumber: | 5034944286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 08/15/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | MD13595 | OR | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207WX0200X | MD13595 | OR | Y |
ID Information
| ID | Type | State | Issuer | Description | 148213 | 05 | OR | MEDICAID | 180040675 | 01 | RAILROAD MEDICARE | OTHER |