Provider Demographics
NPI:1104093665
Name:KANSARA, AMIT (MD)
Entity type:Individual
Prefix:DR
First Name:AMIT
Middle Name:
Last Name:KANSARA
Suffix:
Gender:M
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9135 SW BARNES RD
Practice Address - Street 2:STE 461
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6646
Practice Address - Country:US
Practice Address - Phone:503-216-1150
Practice Address - Fax:971-282-0086
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2022-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD602644622084N0400X
AK1091242084N0400X
MT350252084N0400X
CAA1396262084N0400X
ORMD1568522084N0400X, 2084V0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP01889829OtherRR MEDICARE (PH&S)-PMG
OR500645487Medicaid
ORR164431Medicare PIN
ORR164432Medicare PIN
ORR192450Medicare PIN
ORP01889829OtherRR MEDICARE (PH&S)-PMG