Provider Demographics
NPI:1336267707
Name:KING-WIDDALL, CAROLINE LOUISE (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROLINE
Middle Name:LOUISE
Last Name:KING-WIDDALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CAROLINE
Other - Middle Name:LOUISE
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2925 RIVER RD S
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-9754
Mailing Address - Country:US
Mailing Address - Phone:503-814-4400
Mailing Address - Fax:
Practice Address - Street 1:2925 RIVER RD S
Practice Address - Street 2:SUITE 100
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-9754
Practice Address - Country:US
Practice Address - Phone:503-814-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301087707207Q00000X, 390200000X
ORMD151091207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500622839Medicaid