Provider Demographics
NPI:1083021638
Name:THODA, STOTZ JR (DO)
Entity Type:Individual
Prefix:MR
First Name:STOTZ
Middle Name:
Last Name:THODA
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 SW COLUMBIA ST
Mailing Address - Street 2:STE 6210
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1099
Mailing Address - Country:US
Mailing Address - Phone:541-323-3181
Mailing Address - Fax:
Practice Address - Street 1:4104 SE 82ND AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-2954
Practice Address - Country:US
Practice Address - Phone:503-215-9850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-16
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO185779207Q00000X
ORPG173375207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine