Provider Demographics
NPI:1457767584
Name:RIDDLE, EMILY JUSTUSSON (MD)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:JUSTUSSON
Last Name:RIDDLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:ANN MELOCHE
Other - Last Name:JUSTUSSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:743 SW MAPLECREST CT
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-6407
Mailing Address - Country:US
Mailing Address - Phone:845-242-6856
Mailing Address - Fax:
Practice Address - Street 1:3303 SW BOND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4501
Practice Address - Country:US
Practice Address - Phone:503-494-7772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD1953742084N0400X
KYTP0762084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology