Healthcare Provider Details

I. General information

NPI: 1689178766
Provider Name (Legal Business Name): ROSA JAIME CARBONELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2018
Last Update Date: 11/07/2025
Certification Date: 11/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3181 SW SAM JACKSON PARK RD # L-579
PORTLAND OR
97239-3098
US

IV. Provider business mailing address

3181 SW SAM JACKSON PARK RD # L-579
PORTLAND OR
97239-3098
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-8211
  • Fax:
Mailing address:
  • Phone: 503-494-8211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberMD211258
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberMD70000455
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: