Provider Demographics
NPI:1609101781
Name:RIEDEL, KEVIN (OD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:RIEDEL
Suffix:
Gender:M
Credentials:OD
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 22009
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97269-2009
Mailing Address - Country:US
Mailing Address - Phone:503-558-7372
Mailing Address - Fax:503-344-5140
Practice Address - Street 1:5050 NE HOYT ST STE 445
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2984
Practice Address - Country:US
Practice Address - Phone:503-231-0166
Practice Address - Fax:503-231-2720
Is Sole Proprietor?:No
Enumeration Date:2009-10-07
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3402ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500650374Medicaid