Healthcare Provider Details

I. General information

NPI: 1780806125
Provider Name (Legal Business Name): LAURA FLATH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 12/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24900 SE STARK ST STE 109
GRESHAM OR
97030-3381
US

IV. Provider business mailing address

13580 NW PETTYGROVE ST
PORTLAND OR
97229-4438
US

V. Phone/Fax

Practice location:
  • Phone: 503-674-1950
  • Fax: 503-674-1965
Mailing address:
  • Phone: 503-781-9137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD29028
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: