Provider Demographics
NPI:1881649705
Name:HEYDON, KIM M (MD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:M
Last Name:HEYDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:YOUGDAHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
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 1:5555 NE ELAM YOUNG PKWY
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-6452
Practice Address - Country:US
Practice Address - Phone:503-216-1600
Practice Address - Fax:503-216-1610
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23574207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286956Medicaid
OR118199Medicare ID - Type Unspecified
OR286956Medicaid
ORR118199Medicare PIN