Healthcare Provider Details

I. General information

NPI: 1962487231
Provider Name (Legal Business Name): SANDHYA V KOPPULA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 11/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17200 NW CORRIDOR COURT SUITE 112
BEAVERTON OR
97006-3295
US

IV. Provider business mailing address

17200 NW CORRIDOR COURT SUITE 112
BEAVERTON OR
97006-3295
US

V. Phone/Fax

Practice location:
  • Phone: 503-439-6969
  • Fax: 503-439-6868
Mailing address:
  • Phone: 503-439-6969
  • Fax: 503-439-6868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD18825
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: