Healthcare Provider Details

I. General information

NPI: 1780667527
Provider Name (Legal Business Name): STEPHANIE J MENGDEN KOON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE J MENGDEN MD

II. Dates (important events)

Enumeration Date: 11/25/2005
Last Update Date: 11/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12254 SW GARDEN PL
TIGARD OR
97223-8246
US

IV. Provider business mailing address

PO BOX 230457
TIGARD OR
97281-0457
US

V. Phone/Fax

Practice location:
  • Phone: 503-906-7300
  • Fax: 503-245-8219
Mailing address:
  • Phone: 503-906-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberMD28731
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD28731
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: