Provider Demographics
NPI:1972562809
Name:KUJOVICH, JODY LYNN (MD)
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:LYNN
Last Name:KUJOVICH
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 1:265 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1800
Mailing Address - Country:US
Mailing Address - Phone:503-280-1223
Mailing Address - Fax:503-528-5252
Practice Address - Street 1:265 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1800
Practice Address - Country:US
Practice Address - Phone:503-280-1223
Practice Address - Fax:503-528-5252
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD19371207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1023487Medicaid
OR150201Medicaid
OR150201Medicaid
OR134100Medicare PIN
ORG46762Medicare UPIN