Basic Information
| Provider Information | |||||||||
| NPI: | 1245278993 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUKUMAR | ||||||||
| FirstName: | SHIRIN | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 NW 23RD AVE | ||||||||
| Address2: | LEGACY CLINIC GOOD SAMARITAN | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972102906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034137074 | ||||||||
| FaxNumber: | 5034136769 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 NW 23RD AVE | ||||||||
| Address2: | LEGACY CLINIC GOOD SAMARITAN | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972102906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034137074 | ||||||||
| FaxNumber: | 5034136769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 08/27/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD23728 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0300X | MD23728 | OR | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
No ID Information.