Provider Demographics
NPI:1346348935
Name:HUDDLESTON, LISA A (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:HUDDLESTON
Suffix:
Gender:F
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 3397
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3397
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:727 S WAHANNA ROAD
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:OR
Practice Address - Zip Code:97138-7735
Practice Address - Country:US
Practice Address - Phone:503-717-7556
Practice Address - Fax:503-717-7476
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18816207Q00000X
OR18816207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR128335Medicaid
OR128335Medicaid
ORF53189Medicare UPIN