Healthcare Provider Details

I. General information

NPI: 1730489634
Provider Name (Legal Business Name): ANNIKA MALMBERG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2010
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NE NEFF RD
BEND OR
97701-6015
US

IV. Provider business mailing address

1608 S J ST FLOOR 1
TACOMA WA
98405-4930
US

V. Phone/Fax

Practice location:
  • Phone: 541-526-6635
  • Fax: 541-526-6636
Mailing address:
  • Phone: 253-274-7501
  • Fax: 253-274-7991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA114404
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD60366132
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2036823
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer
# 2
Identifier326439
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerSTATE L&I

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: