Provider Demographics
NPI:1275895112
Name:NERODA, KIMBERLEY ARIANNE (MD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLEY
Middle Name:ARIANNE
Last Name:NERODA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10330 SE 32ND AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-6596
Mailing Address - Country:US
Mailing Address - Phone:503-513-1300
Mailing Address - Fax:
Practice Address - Street 1:10330 SE 32ND AVE STE 110
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-6596
Practice Address - Country:US
Practice Address - Phone:503-513-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-15
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD171411207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500687998Medicaid
ORR182622Medicare PIN