Healthcare Provider Details

I. General information

NPI: 1326625856
Provider Name (Legal Business Name): KEVIN DRISCOLL DPM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
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 Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: DR. KEVIN DRISCOLL
Title or Position: PHYSICIAN
Credential: DPM
Phone: 503-255-8100