Provider Demographics
NPI:1528055548
Name:DUTTA, SAJAL C (MD)
Entity type:Individual
Prefix:DR
First Name:SAJAL
Middle Name:C
Last Name:DUTTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 NE 20TH AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2895
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:501 N GRAHAM ST
Practice Address - Street 2:STE 420
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-2006
Practice Address - Country:US
Practice Address - Phone:503-288-7303
Practice Address - Fax:503-288-3806
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23632208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286467Medicaid
WA8383143Medicaid
WA2147140Medicaid
WA2147140Medicaid
WA7858004Medicaid
CP7690OtherMEDICARE RAILROAD
003395017OtherBLUE CROSS OR ALL
WA0079880OtherDEPT OF LABOR A
WA161520OtherDEPT OF LABOR A
OR286467Medicaid
WA8383143Medicaid
A020OtherTRICARE
H60845OtherPROVIDENCE HEALTH
H60845OtherPROVIDENCE HEALTH
003395017OtherBLUE CROSS OR ALL
CP7690OtherMEDICARE RAILROAD
340020110Medicare ID - Type UnspecifiedMEDICARE RAILROAD
OR109371Medicaid