Provider Demographics
NPI:1306001615
Name:NEWBERG PEDIATRIC CLINIC
Entity Type:Organization
Organization Name:NEWBERG PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAYA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:MANKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-538-7407
Mailing Address - Street 1:308 VILLA RD STE 116
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-1881
Mailing Address - Country:US
Mailing Address - Phone:503-538-7407
Mailing Address - Fax:503-537-0640
Practice Address - Street 1:308 VILLA RD STE 116
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-1881
Practice Address - Country:US
Practice Address - Phone:503-538-7407
Practice Address - Fax:503-537-0640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-25
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10760174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR126565Medicaid
OR126565Medicaid
OR130564Medicare PIN