Shobha N. Jetmalani, M.D.

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

License

MD15615 Issued in OR

Practice address

18040 SW Lower Boones Ferry Rd
Suite 100
Tigard, OR 97224-7258

Phone

(503) 215-0700

Fax

(503) 216-0750

NPI assigned

Feb 27, 2006

Last updated

Oct 11, 2012By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1140998400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1349913600000",
    "number": "1407822687",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3158",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972083158",
            "telephone_number": "503-215-6494",
            "fax_number": "503-215-6644"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "18040 SW LOWER BOONES FERRY RD",
            "address_2": "SUITE 100",
            "city": "TIGARD",
            "state": "OR",
            "postal_code": "972247258",
            "telephone_number": "503-215-0700",
            "fax_number": "503-216-0750"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JETMALANI",
        "first_name": "SHOBHA",
        "middle_name": "N.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-02-27",
        "last_updated": "2012-10-11",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "OR",
            "license": "MD15615",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RR MEDICARE",
            "identifier": "P00818469",
            "state": "OR"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "031216",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Dermatology Physician in Tigard, OR
• Providers in Tigard, OR by specialty
• Dermatology Physician in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 11, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.