Provider Demographics
NPI:1366457871
Name:PANOSCHA, RITA (MD)
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:
Last Name:PANOSCHA
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 1:707 SW GAINES ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-2901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:707 SW GAINES ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2901
Practice Address - Country:US
Practice Address - Phone:800-452-3563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD241742080P0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR181880Medicaid
F51616Medicare UPIN