Provider Demographics
NPI:1558397034
Name:COMARDELLE, ALLA (MD)
Entity Type:Individual
Prefix:
First Name:ALLA
Middle Name:
Last Name:COMARDELLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ALLA
Other - Middle Name:
Other - Last Name:MAKUTONINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5715 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-3223
Mailing Address - Country:US
Mailing Address - Phone:504-481-0116
Mailing Address - Fax:
Practice Address - Street 1:KAISER SUNNYSIDE MEDICAL CENTER
Practice Address - Street 2:10180 SE SUNNYSIDE RD.
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015
Practice Address - Country:US
Practice Address - Phone:503-652-2880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA026067208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1050890Medicaid