Provider Demographics
NPI:1164659637
Name:DVERSDAL, RENEE K (MD)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:K
Last Name:DVERSDAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:K
Other - Last Name:RUTLEDGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:BTE119 OHSU,
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3098
Mailing Address - Country:US
Mailing Address - Phone:503-494-8311
Mailing Address - Fax:
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:BTE119 OHSU,
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3098
Practice Address - Country:US
Practice Address - Phone:503-494-8311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-11
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD157331208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist