Provider Demographics
NPI:1184824237
Name:ROOT, DANIEL C (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:C
Last Name:ROOT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:
Practice Address - Street 1:9280 SE SUNNYSIDE BLVD
Practice Address - Street 2:STE 200
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015
Practice Address - Country:US
Practice Address - Phone:503-962-1840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042937207N00000X
ORMD223071207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8369662Medicaid
WA8369662Medicaid
WAG8801576Medicare PIN
WAG8801574Medicare PIN
WAG8801580Medicare PIN
WAG88771868Medicare PIN
WAG8801578Medicare PIN
WA101700Medicare UPIN