Healthcare Provider Details

I. General information

NPI: 1447893748
Provider Name (Legal Business Name): MARIYA SULAKOV ND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2019
Last Update Date: 12/13/2022
Certification Date: 12/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25500 SE STARK ST ST 202
GRESHAM OR
97030-2441
US

IV. Provider business mailing address

25500 SE STARK ST ST 202
GRESHAM OR
97030-3331
US

V. Phone/Fax

Practice location:
  • Phone: 503-489-5917
  • Fax:
Mailing address:
  • Phone: 503-489-5917
  • Fax: 503-489-9210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number4264
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: