Provider Demographics
NPI:1912184516
Name:RYDBOM, KIMBERLY ANN (DO)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:ANN
Last Name:RYDBOM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 N VANCOUVER AVE STE 230
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1668
Mailing Address - Country:US
Mailing Address - Phone:503-413-2901
Mailing Address - Fax:
Practice Address - Street 1:2800 N VANCOUVER AVE STE 230
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1668
Practice Address - Country:US
Practice Address - Phone:503-413-2901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-25
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLL16582390200000X
ORDO29400207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program