Provider Demographics
NPI:1962487231
Name:KOPPULA, SANDHYA V (MD)
Entity Type:Individual
Prefix:DR
First Name:SANDHYA
Middle Name:V
Last Name:KOPPULA
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 1:17200 NW CORRIDOR COURT
Mailing Address - Street 2:SUITE 112
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-3295
Mailing Address - Country:US
Mailing Address - Phone:503-439-6969
Mailing Address - Fax:503-439-6868
Practice Address - Street 1:17200 NW CORRIDOR COURT
Practice Address - Street 2:SUITE 112
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-3295
Practice Address - Country:US
Practice Address - Phone:503-439-6969
Practice Address - Fax:503-439-6868
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18825207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8180424Medicaid
OR075544Medicaid
OR0000BLBMRMedicare ID - Type Unspecified
OR075544Medicaid