Provider Demographics
NPI:1174690838
Name:MENGIS, MATILDA MARTHA (MD)
Entity Type:Individual
Prefix:
First Name:MATILDA
Middle Name:MARTHA
Last Name:MENGIS
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 1:2721 SW MONTGOMERY DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-1692
Mailing Address - Country:US
Mailing Address - Phone:503-936-2324
Mailing Address - Fax:
Practice Address - Street 1:412 SW 12TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2329
Practice Address - Country:US
Practice Address - Phone:503-228-7134
Practice Address - Fax:503-273-8431
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG833022084P0800X
ORMD235252084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286525Medicaid
OR286525Medicaid
G22358Medicare UPIN