Healthcare Provider Details

I. General information

NPI: 1093926081
Provider Name (Legal Business Name): SUDESHNA BANERJEE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3311 RIVERBEND DR SUITE 300
SPRINGFIELD OR
97477-8800
US

IV. Provider business mailing address

3311 RIVERBEND DR SUITE 300
SPRINGFIELD OR
97477-8800
US

V. Phone/Fax

Practice location:
  • Phone: 541-484-4332
  • Fax:
Mailing address:
  • Phone: 541-484-4332
  • Fax: 541-242-6770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number57.008712
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberMD155880
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: