Provider Demographics
NPI:1740210434
Name:EARDLEY, DIANNE C (MD)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:C
Last Name:EARDLEY
Suffix:
Gender:F
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:417 SW 117TH AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5924
Practice Address - Country:US
Practice Address - Phone:503-216-9400
Practice Address - Fax:503-216-9499
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18802207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR065748Medicaid
OR110084688OtherRR MEDICARE
ORR00WCZBJBMedicare PIN
OR065748Medicaid