Basic Information
| Provider Information | |||||||||
| NPI: | 1801873492 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VIDES | ||||||||
| FirstName: | EDUARDO | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VIDES-LEMUS LOPEZ | ||||||||
| OtherFirstName: | EDUARDO | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 800 SW 13TH AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972051902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032210161 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5005 NE SANDY BLVD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972131941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032336940 | ||||||||
| FaxNumber: | 5032362676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2005 | ||||||||
| LastUpdateDate: | 12/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD00038051 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | OR-MD27304 | OR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8252769 | 05 | WA | MEDICAID | 247628 | 05 | OR | MEDICAID | P00418274 | 01 | OR | RAILROAD MEDICARE | OTHER |