Provider Demographics
NPI:1144911231
Name:MANDUJANO, MARIELLA
Entity type:Individual
Prefix:
First Name:MARIELLA
Middle Name:
Last Name:MANDUJANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11775 SW 134TH TER
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-1581
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11097 SE 21ST AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-7640
Practice Address - Country:US
Practice Address - Phone:503-974-9025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000107858175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist