Provider Demographics
NPI:1093751372
Name:RIDDICK, CARL ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:ANTHONY
Last Name:RIDDICK
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 1:847 NE 19TH AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2684
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:9427 SW BARNES RD STE 296
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6667
Practice Address - Country:US
Practice Address - Phone:503-297-3778
Practice Address - Fax:503-297-7853
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD20646207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2017144Medicaid
OR150111Medicaid
ORF19804Medicare UPIN
OR186513Medicare PIN
OR186512Medicare PIN