Provider Demographics
NPI:1831177385
Name:DEDRICK, DAVID L (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:DEDRICK
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 5579
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97708-5579
Mailing Address - Country:US
Mailing Address - Phone:541-706-6905
Mailing Address - Fax:541-371-4580
Practice Address - Street 1:2042 NE WILLIAMSON CT
Practice Address - Street 2:ST. CHARLES SLEEP CENTER - BEND
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3760
Practice Address - Country:US
Practice Address - Phone:541-706-6905
Practice Address - Fax:541-371-4580
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD19899207RS0012X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287267Medicaid
ORR158511Medicare PIN