Provider Demographics
NPI:1487041687
Name:CRIDER, CARLY ANN MAYUMI (DO)
Entity Type:Individual
Prefix:
First Name:CARLY ANN
Middle Name:MAYUMI
Last Name:CRIDER
Suffix:
Gender:F
Credentials:DO
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 1193
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1193
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 MULLINS DR STE C2
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-2868
Practice Address - Country:US
Practice Address - Phone:541-451-6413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-25
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR193425207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine