Provider Demographics
NPI:1336274075
Name:KIDD, DAVID (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:KIDD
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 735
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-0335
Mailing Address - Country:US
Mailing Address - Phone:503-490-4657
Mailing Address - Fax:
Practice Address - Street 1:12518 NE AIRPORT WAY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-1078
Practice Address - Country:US
Practice Address - Phone:503-256-2992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG59335207R00000X
HIMD13533207R00000X
MI4301065060207R00000X
NV7650207R00000X
ORMD18096207R00000X
WAMD00030390207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH88969Medicare UPIN