Provider Demographics
NPI:1588003677
Name:MUKHERJEE, SOURABH (MD)
Entity Type:Individual
Prefix:MR
First Name:SOURABH
Middle Name:
Last Name:MUKHERJEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD # OP31
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-418-9888
Mailing Address - Fax:
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD # OP31
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-418-9888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-21
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA256630207XS0117X
ORFE165114207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery