Healthcare Provider Details

I. General information

NPI: 1104272921
Provider Name (Legal Business Name): RANDELL PETER JURA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2016
Last Update Date: 07/21/2023
Certification Date: 07/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10915 SE STARK ST
PORTLAND OR
97216-3348
US

IV. Provider business mailing address

10915 SE STARK ST
PORTLAND OR
97216-3348
US

V. Phone/Fax

Practice location:
  • Phone: 503-261-1120
  • Fax: 503-261-8936
Mailing address:
  • Phone: 503-261-1120
  • Fax: 503-261-8936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number12431
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: