Provider Demographics
NPI:1215122833
Name:YAMA A DEHQANZADA DPM PC
Entity type:Organization
Organization Name:YAMA A DEHQANZADA DPM PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:YAMA
Authorized Official - Middle Name:AHMAD
Authorized Official - Last Name:DEHQANZADA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:503-925-8120
Mailing Address - Street 1:16770 SW EDY RD
Mailing Address - Street 2:SUITE 216
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-9678
Mailing Address - Country:US
Mailing Address - Phone:503-925-8120
Mailing Address - Fax:503-925-8121
Practice Address - Street 1:16770 SW EDY RD
Practice Address - Street 2:SUITE 216
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-9678
Practice Address - Country:US
Practice Address - Phone:503-925-8120
Practice Address - Fax:503-925-8121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00348261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1154338275OtherINDIVIDUAL NPI
ORU96890Medicare UPIN