Healthcare Provider Details

I. General information

NPI: 1336267707
Provider Name (Legal Business Name): CAROLINE LOUISE KING-WIDDALL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAROLINE LOUISE KING MD

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5940 ULALI DR NE
KEIZER OR
97303-1500
US

IV. Provider business mailing address

5940 ULALI DR NE
KEIZER OR
97303-1500
US

V. Phone/Fax

Practice location:
  • Phone: 503-813-2000
  • Fax:
Mailing address:
  • Phone: 503-813-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301087707
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD60644334
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301087707
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD151091
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: