Provider Demographics
NPI:1033122502
Name:BHUTTA, OMAR J (MD)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:J
Last Name:BHUTTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 N GANTENBEIN AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1623
Mailing Address - Country:US
Mailing Address - Phone:503-276-6565
Mailing Address - Fax:
Practice Address - Street 1:2801 N GANTENBEIN AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1623
Practice Address - Country:US
Practice Address - Phone:503-276-6565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAML20008350208000000X
NHLT-31892080P0203X
NH159052080P0203X
ORMD1741102080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH32001711Medicaid
OR500693056Medicaid
VT1021010Medicaid