Healthcare Provider Details

I. General information

NPI: 1275579906
Provider Name (Legal Business Name): RUPA K. SHAH, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8645 SE SUNNYBROOK BLVD #200
CLACKAMAS OR
97015-6841
US

IV. Provider business mailing address

8645 SE SUNNYBROOK BLVD #200
CLACKAMAS OR
97015-6841
US

V. Phone/Fax

Practice location:
  • Phone: 503-659-1694
  • Fax: 503-659-8984
Mailing address:
  • Phone: 503-659-1694
  • Fax: 503-659-8984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier287686
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: MRS. RUPA KIRIT SHAH
Title or Position: COMPANY PRESIDENT MEDICAL DIRECTOR
Credential: MD
Phone: 503-659-1694