Provider Demographics
NPI:1538172119
Name:STANDRIDGE, WALTER L (MD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:L
Last Name:STANDRIDGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10180 SE SUNNYSIDE RD
Mailing Address - Street 2:WING A
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-8970
Mailing Address - Country:US
Mailing Address - Phone:503-571-0892
Mailing Address - Fax:503-571-0867
Practice Address - Street 1:10180 SE SUNNYSIDE RD
Practice Address - Street 2:WING A
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-8970
Practice Address - Country:US
Practice Address - Phone:503-571-0892
Practice Address - Fax:503-571-0867
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO32903208M00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO12300063Medicaid
438448Medicare ID - Type Unspecified
CO12300063Medicaid