Provider Demographics
NPI:1588195259
Name:GLASS, SARAH TANAKA (MD)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:TANAKA
Last Name:GLASS
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 1:1955 NW NORTHRUP ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-1614
Mailing Address - Country:US
Mailing Address - Phone:503-227-2020
Mailing Address - Fax:
Practice Address - Street 1:1955 NW NORTHRUP ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1614
Practice Address - Country:US
Practice Address - Phone:503-227-2020
Practice Address - Fax:503-222-0614
Is Sole Proprietor?:No
Enumeration Date:2017-03-24
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORMD204309207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500794226Medicaid
ORR227666OtherMEDICARE