Healthcare Provider Details

I. General information

NPI: 1891179644
Provider Name (Legal Business Name): ALEXANDER KOTUKHOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2015
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

3181 SW SAM JACKSON PARK RD MAIL CODE SJH-2
PORTLAND OR
97239-1837
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-7641
  • Fax: 503-494-4661
Mailing address:
  • Phone: 503-494-7246
  • Fax: 503-494-8368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125.067855
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number54039
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD213814
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: