Provider Demographics
NPI:1780667527
Name:MENGDEN KOON, STEPHANIE J (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:J
Last Name:MENGDEN KOON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:J
Other - Last Name:MENGDEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 230457
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97281-0457
Mailing Address - Country:US
Mailing Address - Phone:503-906-7300
Mailing Address - Fax:
Practice Address - Street 1:12254 SW GARDEN PL
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8246
Practice Address - Country:US
Practice Address - Phone:503-906-7300
Practice Address - Fax:503-245-8219
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD28731207ND0900X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H95915Medicare UPIN