Healthcare Provider Details

I. General information

NPI: 1104029354
Provider Name (Legal Business Name): SVATI VALIA NICHOLSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SVATI M VALIA

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3181 SW SAM JACKSON PARK RD
PORTLAND OR
97239-3011
US

IV. Provider business mailing address

3931 NE 42ND AVE
PORTLAND OR
97213-1009
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-9000
  • Fax:
Mailing address:
  • Phone: 503-810-4391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberLL16255
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: