Healthcare Provider Details

I. General information

NPI: 1851658470
Provider Name (Legal Business Name): TANVI HATHIWALA MUKUNDAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2012
Last Update Date: 08/17/2020
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3710 SW US VETERANS HOSPITAL RD P3 PULM
PORTLAND OR
97239-2964
US

IV. Provider business mailing address

3710 SW US VETERANS HOSPITAL RD P3 PULM
PORTLAND OR
97239-2964
US

V. Phone/Fax

Practice location:
  • Phone: 503-220-8262
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080S0012X
TaxonomyPediatric Sleep Medicine Physician
License NumberMD171943
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: