Provider Demographics
NPI:1649955980
Name:SUDAISAR, SCOTT DESI
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:DESI
Last Name:SUDAISAR
Suffix:
Gender:M
Credentials:
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 1238
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-8238
Mailing Address - Country:US
Mailing Address - Phone:503-349-5828
Mailing Address - Fax:
Practice Address - Street 1:22350 SW PINE ST
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-9075
Practice Address - Country:US
Practice Address - Phone:503-349-5828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR083697405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes405300000XOther Service ProvidersPrevention ProfessionalGroup - Single Specialty