Provider Demographics
NPI:1487729281
Name:THURMOND, AMY SUZANNE (MD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:SUZANNE
Last Name:THURMOND
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 1:17050 PILKINGTON RD
Mailing Address - Street 2:130
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-6306
Mailing Address - Country:US
Mailing Address - Phone:503-305-5432
Mailing Address - Fax:503-305-7294
Practice Address - Street 1:17050 PILKINGTON RD
Practice Address - Street 2:130
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-6306
Practice Address - Country:US
Practice Address - Phone:503-305-5432
Practice Address - Fax:503-305-7294
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD136912085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR021675Medicaid
OR106192Medicare ID - Type Unspecified
D95249Medicare UPIN