Provider Demographics
NPI:1972591618
Name:PANWALA, KATHRYN VICTORIA (MD)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:VICTORIA
Last Name:PANWALA
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 1:1400 NW IRVING ST
Mailing Address - Street 2:527
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2210
Mailing Address - Country:US
Mailing Address - Phone:503-222-1299
Mailing Address - Fax:
Practice Address - Street 1:24950 SE STARK ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3379
Practice Address - Country:US
Practice Address - Phone:503-674-1152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2007-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD250252085R0001X, 2085R0203X
WAMD000433802085R0001X, 2085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR118792Medicare PIN
ORR118490Medicare PIN
G8855376Medicare PIN