Basic Information
| Provider Information | |||||||||
| NPI: | 1932129491 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUKUL | ||||||||
| FirstName: | LIBERATO | ||||||||
| MiddleName: | V | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7650 SW BEVELAND RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972238692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037343535 | ||||||||
| FaxNumber: | 5037343530 | ||||||||
| Practice Location | |||||||||
| Address1: | 9701 SW BARNES RD | ||||||||
| Address2: | STE 150 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972256772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037343535 | ||||||||
| FaxNumber: | 5037343530 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 06/23/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | MD 28165 | OR | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 241654 | 05 | OR | MEDICAID | R154890 | 01 | OR | MEDICARE PTAN | OTHER |