Healthcare Provider Details

I. General information

NPI: 1952667974
Provider Name (Legal Business Name): RAJ PENUMETSA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2012
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 NE 2ND AVE
PORTLAND OR
97232-2003
US

IV. Provider business mailing address

2750 PICKLE RD APT 11
OREGON OH
43616-3935
US

V. Phone/Fax

Practice location:
  • Phone: 503-944-8000
  • Fax:
Mailing address:
  • Phone: 567-277-0342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberU9769
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number35.126661
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD220293
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: