Provider Demographics
NPI:1528250131
Name:MUDRICK, MEGAN LEAR (MD)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:LEAR
Last Name:MUDRICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:ELIZABETH
Other - Last Name:LEAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
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 1:417 SW 117TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5924
Practice Address - Country:US
Practice Address - Phone:503-216-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036118322207Q00000X
KS04-34032207Q00000X
VA0101243296207Q00000X
ORMD164511207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500676578Medicaid
VA1528250131Medicaid
VA1528250131Medicaid
OR500676578Medicaid