Provider Demographics
NPI:1053535120
Name:BASHAM, DERWOOD E (DO)
Entity type:Individual
Prefix:DR
First Name:DERWOOD
Middle Name:E
Last Name:BASHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2371 NE STEPHENS ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-1372
Mailing Address - Country:US
Mailing Address - Phone:541-672-8533
Mailing Address - Fax:541-672-4993
Practice Address - Street 1:2371 NE STEPHENS ST
Practice Address - Street 2:SUITE 200
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-1372
Practice Address - Country:US
Practice Address - Phone:541-672-8533
Practice Address - Fax:541-672-4993
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO171270207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR165772Medicaid
KY7100032070Medicaid
KY00164003Medicare PIN