Provider Demographics
NPI:1356305023
Name:WESTERDAHL, DAVID N (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:N
Last Name:WESTERDAHL
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 1:12672 NW BARNES RD STE 100
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-6191
Mailing Address - Country:US
Mailing Address - Phone:503-747-6376
Mailing Address - Fax:503-530-8406
Practice Address - Street 1:12672 NW BARNES RD STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-6191
Practice Address - Country:US
Practice Address - Phone:503-747-6376
Practice Address - Fax:503-530-8406
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2020-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0084094207QS0010X
ORMD186427207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270794200Medicaid
FL15555YMedicare ID - Type Unspecified