Provider Demographics
NPI:1609215987
Name:KIWALKAR, SONAM RAVINDRA (MD)
Entity Type:Individual
Prefix:
First Name:SONAM
Middle Name:RAVINDRA
Last Name:KIWALKAR
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 1:3181 SW SAM JACKSON PARK RD
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:503-494-4300
Mailing Address - Fax:503-494-4323
Practice Address - Street 1:700 NE 87TH AVE STE 330
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-4896
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:360-604-1730
Is Sole Proprietor?:No
Enumeration Date:2013-06-19
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61065748207R00000X, 207RR0500X
ORMD194449207R00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2041321Medicaid