1801873492 NPI number — EDUARDO A VIDES MD

Table of content: EDUARDO A VIDES MD (NPI 1801873492)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801873492 NPI number — EDUARDO A VIDES MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VIDES
Provider First Name:
EDUARDO
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VIDES-LEMUS LOPEZ
Provider Other First Name:
EDUARDO
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1801873492
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 SW 13TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97205-1902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-221-0161
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5005 NE SANDY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97213-1941
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-233-6940
Provider Business Practice Location Address Fax Number:
503-236-2676
Provider Enumeration Date:
12/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  MD00038051 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: OR-MD27304 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8252769 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 247628 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00418274 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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