Healthcare Provider Details

I. General information

NPI: 1972678845
Provider Name (Legal Business Name): PRASANTH M PRASANNA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2006
Last Update Date: 12/20/2023
Certification Date: 12/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 SE 8TH AVE
HILLSBORO OR
97123-4246
US

IV. Provider business mailing address

1400 SW 5TH AVE STE 500
PORTLAND OR
97201-5537
US

V. Phone/Fax

Practice location:
  • Phone: 503-681-1100
  • Fax: 503-681-1835
Mailing address:
  • Phone: 503-494-8417
  • Fax: 503-494-4455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD156365
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: