Provider Demographics
NPI:1396871083
Name:FOKSHA, PAVEL
Entity type:Individual
Prefix:
First Name:PAVEL
Middle Name:
Last Name:FOKSHA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:HEALTHCARE
Other - Middle Name:MEDICAL
Other - Last Name:SUPPLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4000 SE 82ND AVE
Mailing Address - Street 2:SUITE 1500
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-2924
Mailing Address - Country:US
Mailing Address - Phone:503-772-5333
Mailing Address - Fax:503-772-5366
Practice Address - Street 1:4000 SE 82ND AVE
Practice Address - Street 2:SUITE 1500
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-2924
Practice Address - Country:US
Practice Address - Phone:503-772-5333
Practice Address - Fax:503-772-5366
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR653593332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR274628Medicaid
OR4080340001Medicare NSC