Healthcare Provider Details

I. General information

NPI: 1073794988
Provider Name (Legal Business Name): SANDRA J KRUSSEL D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2007
Last Update Date: 02/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 NW FLANDERS ST SUITE 306
PORTLAND OR
97210-3443
US

IV. Provider business mailing address

2250 NW FLANDERS ST SUITE 306
PORTLAND OR
97210-3443
US

V. Phone/Fax

Practice location:
  • Phone: 503-226-0558
  • Fax: 503-276-1284
Mailing address:
  • Phone: 503-226-0558
  • Fax: 503-276-1284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberDO152642
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License NumberDO152642
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: