Healthcare Provider Details

I. General information

NPI: 1467531160
Provider Name (Legal Business Name): KARAN S. RANDHAVA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 12/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3810 SE DIVISION ST STE C
PORTLAND OR
97202
US

IV. Provider business mailing address

7515 SW CORBETT AVE
PORTLAND OR
97219-2909
US

V. Phone/Fax

Practice location:
  • Phone: 503-376-7114
  • Fax:
Mailing address:
  • Phone: 503-784-8667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD25932
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD25932
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: