Provider Demographics
NPI:1104890011
Name:CADDY, LANCE J (MD)
Entity type:Individual
Prefix:DR
First Name:LANCE
Middle Name:J
Last Name:CADDY
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:PO BOX 2040
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-2040
Mailing Address - Country:US
Mailing Address - Phone:503-299-9906
Mailing Address - Fax:503-225-9002
Practice Address - Street 1:707 SW WASHINGTON ST
Practice Address - Street 2:SUITE 700
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-3536
Practice Address - Country:US
Practice Address - Phone:503-299-9906
Practice Address - Fax:503-225-9002
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD12078207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR757051043OtherRR MEDICARE
AKMD842ORMedicaid
OR170738Medicaid
WA8124398Medicaid
WA8124398Medicaid
00WCJPPS1Medicare ID - Type Unspecified