Basic Information
| Provider Information | |||||||||
| NPI: | 1871574947 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAEYENS | ||||||||
| FirstName: | EDGAR | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1793 13TH ST SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973022541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033628385 | ||||||||
| FaxNumber: | 5033628435 | ||||||||
| Practice Location | |||||||||
| Address1: | 375 PARK AVE | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974202242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412677543 | ||||||||
| FaxNumber: | 5412672076 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 12/05/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0101X | MD08528 | OR | Y | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery |
No ID Information.