Healthcare Provider Details

I. General information

NPI: 1174733596
Provider Name (Legal Business Name): ANUR VENKATACHALAPATHI PRAVEEN M.D. , M.P.H
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 503-494-8652
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301083575
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: