Provider Demographics
NPI:1578762035
Name:KRISHNASAMY, PRASANNA VENKATESH (MD, MPH)
Entity Type:Individual
Prefix:
First Name:PRASANNA
Middle Name:VENKATESH
Last Name:KRISHNASAMY
Suffix:
Gender:M
Credentials:MD, MPH
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Other - Middle Name:
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Mailing Address - Street 1:2800 N VANCOUVER AVE
Mailing Address - Street 2:SUITE 230 (LEGACY MEDICAL GROUP - EMANUEL)
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1630
Mailing Address - Country:US
Mailing Address - Phone:503-413-4340
Mailing Address - Fax:503-413-4898
Practice Address - Street 1:2800 N VANCOUVER AVE
Practice Address - Street 2:SUITE 230 (LEGACY MEDICAL GROUP - EMANUEL)
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1630
Practice Address - Country:US
Practice Address - Phone:503-413-4340
Practice Address - Fax:503-413-4898
Is Sole Proprietor?:No
Enumeration Date:2007-07-15
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD125896207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine