Provider Demographics
NPI:1790974145
Name:VISHWAKARMA, MOTI LAL (MD)
Entity Type:Individual
Prefix:DR
First Name:MOTI
Middle Name:LAL
Last Name:VISHWAKARMA
Suffix:
Gender:M
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:PO BOX 8100
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97303-0900
Mailing Address - Country:US
Mailing Address - Phone:503-399-2424
Mailing Address - Fax:503-589-6241
Practice Address - Street 1:2531 BOONE RD SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97306-9675
Practice Address - Country:US
Practice Address - Phone:503-399-2424
Practice Address - Fax:503-585-2961
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD189840207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine