Provider Demographics
NPI:1699771956
Name:GOPAL, YASODHA R (MD)
Entity type:Individual
Prefix:
First Name:YASODHA
Middle Name:R
Last Name:GOPAL
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 1:9119 NW MCKENNA DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-8039
Mailing Address - Country:US
Mailing Address - Phone:503-297-6409
Mailing Address - Fax:
Practice Address - Street 1:2525 NW LOVEJOY ST
Practice Address - Street 2:STE 200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2863
Practice Address - Country:US
Practice Address - Phone:503-227-0671
Practice Address - Fax:503-227-0676
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD233132251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287394Medicaid