Provider Demographics
NPI:1447287701
Name:EIDEMILLER, LARRY R (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:R
Last Name:EIDEMILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9155 SW BARNES RD
Mailing Address - Street 2:SUITE 830
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6625
Mailing Address - Country:US
Mailing Address - Phone:503-229-7339
Mailing Address - Fax:503-229-7938
Practice Address - Street 1:1130 NW 22ND AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2900
Practice Address - Country:US
Practice Address - Phone:503-229-7339
Practice Address - Fax:503-229-7938
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2008-05-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ORMD07236208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR234799Medicaid
OR234799Medicaid
OR0000WCGDGDMedicare PIN