Provider Demographics
NPI:1386932580
Name:KADYROVA, ELVIRA V (MD)
Entity type:Individual
Prefix:
First Name:ELVIRA
Middle Name:V
Last Name:KADYROVA
Suffix:
Gender:F
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 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1450 NORTHWEST LN SE STE A
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-6908
Practice Address - Country:US
Practice Address - Phone:360-491-4460
Practice Address - Fax:360-491-3090
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60400832207Q00000X
ORMD166685207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine