Healthcare Provider Details

I. General information

NPI: 1124451521
Provider Name (Legal Business Name): SUZANNE PATRICIA FUNKHOUSER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2013
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10330 SE 32ND AVE STE 305
MILWAUKIE OR
97222-6596
US

IV. Provider business mailing address

PO BOX 3158
PORTLAND OR
97208-3158
US

V. Phone/Fax

Practice location:
  • Phone: 503-513-1800
  • Fax:
Mailing address:
  • Phone: 503-215-6494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD206223
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: