Healthcare Provider Details

I. General information

NPI: 1578776670
Provider Name (Legal Business Name): CHERYL C. TIDBALL DO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 NE BURNSIDE RD SUITE 101
GRESHAM OR
97030-6722
US

IV. Provider business mailing address

1217 NE BURNSIDE RD SUITE 101
GRESHAM OR
97030-6722
US

V. Phone/Fax

Practice location:
  • Phone: 503-489-0663
  • Fax: 503-666-5644
Mailing address:
  • Phone: 503-489-0663
  • Fax: 503-666-5644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberDO19432
License Number StateOR

VIII. Authorized Official

Name: DR. CHERYL C. TIDBALL
Title or Position: PHYSICIAN
Credential: D.O.
Phone: 503-489-0663