Provider Demographics
NPI:1457771305
Name:SANDERSON DISSANAYAKE, TAMARA RENEE (MD)
Entity Type:Individual
Prefix:DR
First Name:TAMARA
Middle Name:RENEE
Last Name:SANDERSON DISSANAYAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TAMARA
Other - Middle Name:RENEE
Other - Last Name:SANDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1715
Mailing Address - Country:US
Mailing Address - Phone:503-367-9089
Mailing Address - Fax:503-621-2235
Practice Address - Street 1:703 NE HANCOCK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3955
Practice Address - Country:US
Practice Address - Phone:503-230-9875
Practice Address - Fax:503-331-3441
Is Sole Proprietor?:No
Enumeration Date:2014-04-18
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61333136207Q00000X
ORMD175860207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500672900Medicaid