Provider Demographics
NPI:1801873492
Name:VIDES, EDUARDO A (MD)
Entity type:Individual
Prefix:
First Name:EDUARDO
Middle Name:A
Last Name:VIDES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:EDUARDO
Other - Middle Name:A
Other - Last Name:VIDES-LEMUS LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:800 SW 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1902
Mailing Address - Country:US
Mailing Address - Phone:503-221-0161
Mailing Address - Fax:
Practice Address - Street 1:5005 NE SANDY BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1941
Practice Address - Country:US
Practice Address - Phone:503-233-6940
Practice Address - Fax:503-236-2676
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00038051207R00000X
OROR-MD27304207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8252769Medicaid
OR247628Medicaid
ORP00418274OtherRAILROAD MEDICARE
WA8252769Medicaid
OR137427Medicare PIN
ORP00418274OtherRAILROAD MEDICARE