Healthcare Provider Details

I. General information

NPI: 1245222512
Provider Name (Legal Business Name): MANOHAR MULKI PUNJA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24900 SE STARK ST SUITE 103
GRESHAM OR
97030-3355
US

IV. Provider business mailing address

975 SE SANDY BLVD SUITE 200
PORTLAND OR
97214-1308
US

V. Phone/Fax

Practice location:
  • Phone: 503-665-4278
  • Fax: 503-665-7766
Mailing address:
  • Phone: 503-963-2846
  • Fax: 503-963-9505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD08438
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: