Provider Demographics
NPI:1053379826
Name:REICHERTER, PAUL DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:DOUGLAS
Last Name:REICHERTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1813 W HARVARD AVE
Mailing Address - Street 2:STE 310
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-2752
Mailing Address - Country:US
Mailing Address - Phone:541-672-7546
Mailing Address - Fax:541-957-8446
Practice Address - Street 1:1813 W HARVARD AVE
Practice Address - Street 2:STE 310
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2752
Practice Address - Country:US
Practice Address - Phone:541-672-7546
Practice Address - Fax:541-957-8446
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015039802207N00000X, 207NS0135X, 207NP0225X, 207ND0101X, 207ND0900X
ORMD23536207N00000X, 207ND0900X, 207NP0225X, 207NS0135X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286785Medicaid
OR838392000OtherBLUE CROSS
ORDC5977OtherRAILROAD MEDICARE
MO1053379826Medicaid
OR38D1028702OtherCLIA #
OR38D1028702OtherCLIA #