Provider Demographics
NPI:1699808931
Name:ERDMAN, KENNETH JAMES (OD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JAMES
Last Name:ERDMAN
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 1:5722 NW 203RD PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-7187
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12300 SE 82ND AVE
Practice Address - Street 2:JCPENNEY OPTICAL
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-7717
Practice Address - Country:US
Practice Address - Phone:503-653-5935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2989T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR075 0553367OtherEYEMED