Provider Demographics
NPI:1255836128
Name:BHAGYAM, CHELLA R (DO)
Entity Type:Individual
Prefix:
First Name:CHELLA
Middle Name:R
Last Name:BHAGYAM
Suffix:
Gender:F
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: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:541-732-8790
Mailing Address - Fax:
Practice Address - Street 1:70 BOWER DR STE 240
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-3689
Practice Address - Country:US
Practice Address - Phone:541-732-8790
Practice Address - Fax:541-732-3415
Is Sole Proprietor?:No
Enumeration Date:2018-03-24
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO211472207Q00000X, 207QS0010X, 207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500807581Medicaid