Provider Demographics
NPI:1598787426
Name:RADHAKRISHNAN, LATHA S (MD)
Entity Type:Individual
Prefix:DR
First Name:LATHA
Middle Name:S
Last Name:RADHAKRISHNAN
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 1:9450 SW BARNES RD STE 100
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6642
Mailing Address - Country:US
Mailing Address - Phone:503-292-9560
Mailing Address - Fax:503-292-9510
Practice Address - Street 1:9450 SW BARNES RD STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6642
Practice Address - Country:US
Practice Address - Phone:503-292-9560
Practice Address - Fax:503-292-9510
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23902207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278224Medicaid
OR133148Medicare ID - Type Unspecified
OR145920Medicare UPIN