Healthcare Provider Details

I. General information

NPI: 1699272724
Provider Name (Legal Business Name): KEVIN DENNIS DRISCOLL DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 09/30/2021
Certification Date: 04/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6108 NE GLISAN ST
PORTLAND OR
97213-3864
US

IV. Provider business mailing address

6108 NE GLISAN ST
PORTLAND OR
97213-3864
US

V. Phone/Fax

Practice location:
  • Phone: 503-255-8100
  • Fax: 503-255-2728
Mailing address:
  • Phone: 503-255-8100
  • Fax: 503-255-2728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number000000
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License NumberSC006916
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberDP202065
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberSC006916
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberDP202065
License Number StateOR
# 6
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License NumberDP202065
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: