Provider Demographics
NPI:1578632469
Name:KAKODKAR, SWATI S (MD)
Entity Type:Individual
Prefix:
First Name:SWATI
Middle Name:S
Last Name:KAKODKAR
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:15640 NW LAIDLAW RD
Practice Address - Street 2:SUITE 102
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-3828
Practice Address - Country:US
Practice Address - Phone:503-764-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD152532207Q00000X
WAMD00047611207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500627227Medicaid
OR293879OtherWA L&I
ORP00893287OtherRR MEDICARE
WAMD00047611OtherLICENSE
ORP00893287OtherRR MEDICARE
WAMD00047611OtherLICENSE