Healthcare Provider Details

I. General information

NPI: 1376602292
Provider Name (Legal Business Name): SUSAN GROVER COLASURDO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 SW 5TH AVE UNIT 806
PORTLAND OR
97201-5422
US

IV. Provider business mailing address

1500 SW 5TH AVE UNIT 806
PORTLAND OR
97201-5422
US

V. Phone/Fax

Practice location:
  • Phone: 541-913-8643
  • Fax: 541-366-4451
Mailing address:
  • Phone: 541-653-9619
  • Fax: 541-366-4451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD14419
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: