Provider Demographics
NPI:1366623134
Name:MT. HOOD PODIATRY
Entity Type:Organization
Organization Name:MT. HOOD PODIATRY
Other - Org Name:MT HOOD PODIATRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAURAS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:541-386-1006
Mailing Address - Street 1:1100 E MARINA WAY
Mailing Address - Street 2:SUITE 223
Mailing Address - City:HOOD RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97031-2305
Mailing Address - Country:US
Mailing Address - Phone:541-386-1006
Mailing Address - Fax:541-386-1284
Practice Address - Street 1:1100 EAST MARINA WAY
Practice Address - Street 2:SUITE 223
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-9540
Practice Address - Country:US
Practice Address - Phone:541-386-1006
Practice Address - Fax:541-386-1284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00203213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0348910001Medicare NSC
OR0348910002Medicare NSC
OR0348910001Medicare NSC