Provider Demographics
NPI:1568564912
Name:LIDDY, JOHN BRIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BRIAN
Last Name:LIDDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PAX
Other - Middle Name:
Other - Last Name:ANESTHESIA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 7247
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97475-0011
Mailing Address - Country:US
Mailing Address - Phone:541-686-9551
Mailing Address - Fax:541-687-6716
Practice Address - Street 1:3333 RIVERBEND DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-8800
Practice Address - Country:US
Practice Address - Phone:541-222-3154
Practice Address - Fax:503-225-9002
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD154919207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500637179Medicaid