Individual
FREDERIC J VAN DIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2801 NW MERCY DR, STE. 300, ROSEBURG, OR 97471
(541) 677-1555
(541) 677-6543
Mailing address
201 NW MEDICAL LOOP STE 190, ROSEBURG, OR 97471-8835
(541) 677-4319
(541) 677-2294
Taxonomy
Speciality
Code
Description
License number
State
207RC0000X
Cardiovascular Disease Physician
Primary
MD12356
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
060070869
RAILROAD MEDICARE
OR
05
—
114173
—
OR
01
—
MD12356
LICENSE
OR
Enumeration date
01/27/2006
Last updated
05/26/2020
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