Provider Demographics
NPI:1760619357
Name:KURIAKOSE, DANA CLARK (MD)
Entity Type:Individual
Prefix:DR
First Name:DANA
Middle Name:CLARK
Last Name:KURIAKOSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DANA
Other - Middle Name:MARIE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 96224
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97296-6004
Mailing Address - Country:US
Mailing Address - Phone:908-303-2105
Mailing Address - Fax:
Practice Address - Street 1:17885 NW EVERGREEN PKWY
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-7494
Practice Address - Country:US
Practice Address - Phone:888-414-3531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME119316208100000X
ORMD209098208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014589800Medicaid