Healthcare Provider Details

I. General information

NPI: 1962454934
Provider Name (Legal Business Name): CLIFFORD DONALD MAH D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 01/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12400 NW CORNELL RD SUITE 201
PORTLAND OR
97229-5693
US

IV. Provider business mailing address

12400 NW CORNELL RD SUITE 201
PORTLAND OR
97229-5693
US

V. Phone/Fax

Practice location:
  • Phone: 503-643-1737
  • Fax: 503-643-4926
Mailing address:
  • Phone: 503-643-1737
  • Fax: 503-643-4926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberDP00369
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: