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General NPI Number Information
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NPI Number | 1578776670
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Entity Type | Organization
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Legal Business Name | CHERYL C. TIDBALL DO PC
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Dates
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Enumeration Date | 05/07/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1217 NE BURNSIDE RD SUITE 101
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City | GRESHAM
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State | OR
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Zip | 97030-6722
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Country | US
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Telephone | 503-489-0663
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Fax | 503-666-5644
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Provider Business Mailing Address
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Address Line | 1217 NE BURNSIDE RD SUITE 101
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City | GRESHAM
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State | OR
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Zip | 97030-6722
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Country | US
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Telephone | 503-489-0663
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Fax | 503-666-5644
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. CHERYL C. TIDBALL
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Credential | D.O.
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Telephone | 503-489-0663
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | DO19432
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License Number State | OR
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