Provider Demographics
NPI:1801462080
Name:MY OTHER ME
Entity type:Organization
Organization Name:MY OTHER ME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:AFSARI-HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:503-522-1446
Mailing Address - Street 1:2343 SE 57TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-4005
Mailing Address - Country:US
Mailing Address - Phone:503-522-1446
Mailing Address - Fax:
Practice Address - Street 1:519 SW PARK AVE STE 304
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-3204
Practice Address - Country:US
Practice Address - Phone:503-522-1446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-28
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5006254Medicaid