Provider Demographics
NPI:1487630042
Name:FIALA, MARTHA L (PT)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:L
Last Name:FIALA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12525 SW TOOZE RD
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-8442
Mailing Address - Country:US
Mailing Address - Phone:503-319-8848
Mailing Address - Fax:
Practice Address - Street 1:403 SW DENNIS AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-3928
Practice Address - Country:US
Practice Address - Phone:503-640-3803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0280174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR838351001OtherBLUE CROSS BLUE SHEILD
OR015128Medicaid
OR838351001OtherBLUE CROSS BLUE SHEILD