Provider Demographics
NPI:1245222512
Name:PUNJA, MANOHAR MULKI (MD)
Entity Type:Individual
Prefix:
First Name:MANOHAR
Middle Name:MULKI
Last Name:PUNJA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:975 SE SANDY BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1308
Mailing Address - Country:US
Mailing Address - Phone:503-963-2846
Mailing Address - Fax:503-963-9505
Practice Address - Street 1:24900 SE STARK ST
Practice Address - Street 2:SUITE 103
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3355
Practice Address - Country:US
Practice Address - Phone:503-665-4278
Practice Address - Fax:503-665-7766
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD08438207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1089895Medicaid
OR150698Medicaid
ORC94479Medicare UPIN
WA1089895Medicaid