Provider Demographics
NPI:1225303316
Name:AVERY, NAOMI SUDA (MD)
Entity Type:Individual
Prefix:
First Name:NAOMI
Middle Name:SUDA
Last Name:AVERY
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 1:619 NW 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3964
Mailing Address - Country:US
Mailing Address - Phone:503-988-7468
Mailing Address - Fax:503-988-3015
Practice Address - Street 1:600 NE 8TH ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7317
Practice Address - Country:US
Practice Address - Phone:503-988-5155
Practice Address - Fax:503-988-5185
Is Sole Proprietor?:No
Enumeration Date:2012-03-21
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAML 60286843207R00000X
WAMD 60484278207R00000X
WAMD60484278207R00000X, 207RG0300X
ORMD175883207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR096511Medicaid
OR022959Medicaid
ORR0000WCJHTMedicare Oscar/Certification