Provider Demographics
NPI:1073794988
Name:KRUSSEL, SANDRA J (DO)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:J
Last Name:KRUSSEL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2250 NW FLANDERS ST
Mailing Address - Street 2:SUITE 306
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3443
Mailing Address - Country:US
Mailing Address - Phone:503-226-0558
Mailing Address - Fax:503-276-1284
Practice Address - Street 1:2250 NW FLANDERS ST
Practice Address - Street 2:SUITE 306
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3443
Practice Address - Country:US
Practice Address - Phone:503-226-0558
Practice Address - Fax:503-276-1284
Is Sole Proprietor?:No
Enumeration Date:2007-11-19
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO1526422084P0800X, 2084P0015X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500631009Medicaid
ORR158527Medicare PIN