Provider Demographics
NPI:1649263088
Name:SERRA, CONSTANCE M (MD)
Entity type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:M
Last Name:SERRA
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 1:849 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:HOOD RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97031-1956
Mailing Address - Country:US
Mailing Address - Phone:541-386-6380
Mailing Address - Fax:541-308-8396
Practice Address - Street 1:849 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-1956
Practice Address - Country:US
Practice Address - Phone:541-386-6380
Practice Address - Fax:541-308-8396
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD20683207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR136277Medicaid
111897Medicare ID - Type Unspecified
OR136277Medicaid