Provider Demographics
NPI:1013640648
Name:EGDORF, JOHN (DPM)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:EGDORF
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-4104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1015 NW 22ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3025
Practice Address - Country:US
Practice Address - Phone:503-413-8401
Practice Address - Fax:503-413-7361
Is Sole Proprietor?:No
Enumeration Date:2022-07-01
Last Update Date:2023-06-24
Deactivation Date:2023-03-20
Deactivation Code:
Reactivation Date:2023-06-22
Provider Licenses
StateLicense IDTaxonomies
ORPG216238390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program