Provider Demographics
NPI:1154914232
Name:WONDERFUL MEDICAL GROUP PC
Entity type:Organization
Organization Name:WONDERFUL MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:KATZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-404-9910
Mailing Address - Street 1:PO BOX 1714
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97075-1714
Mailing Address - Country:US
Mailing Address - Phone:503-208-4116
Mailing Address - Fax:503-213-6510
Practice Address - Street 1:920 SW 6TH AVE STE 1200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-1212
Practice Address - Country:US
Practice Address - Phone:503-208-4116
Practice Address - Fax:503-213-6510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-19
Last Update Date:2021-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty