Provider Demographics
NPI:1093850919
Name:MUCHA, TERRACE R (MD)
Entity Type:Individual
Prefix:
First Name:TERRACE
Middle Name:R
Last Name:MUCHA
Suffix:
Gender:F
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:541-734-3430
Mailing Address - Fax:541-734-3638
Practice Address - Street 1:965 ELLENDALE DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8215
Practice Address - Country:US
Practice Address - Phone:541-734-3430
Practice Address - Fax:541-734-3638
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD153918207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR246216Medicaid
ORR184475Medicare PIN
OR246216Medicaid
ID77119OtherBC PLMC
ORP01060085OtherMEDICARE RAILROAD
ID11000811Medicare PIN
ID000010163859OtherBC SRMC
ID000010163858OtherBS PLMC
IDB6136OtherBC SRMC