Healthcare Provider Details

I. General information

NPI: 1992775092
Provider Name (Legal Business Name): ANANDITA TIWARI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 06/07/2022
Certification Date: 06/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 S PINE ST
CANYONVILLE OR
97417-9648
US

IV. Provider business mailing address

PO BOX 888
CANYONVILLE OR
97417-0888
US

V. Phone/Fax

Practice location:
  • Phone: 541-839-4211
  • Fax: 541-839-4983
Mailing address:
  • Phone: 541-839-4211
  • Fax: 541-839-4983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number38D2107406
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD26035
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: