1699770057 NPI number — DR. TIMOTHY J. GRAY II D.O.

Table of content: DR. TIMOTHY J. GRAY II D.O. (NPI 1699770057)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699770057 NPI number — DR. TIMOTHY J. GRAY II D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAY
Provider First Name:
TIMOTHY
Provider Middle Name:
J.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
II
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699770057
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 189
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOREST GROVE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97116-0189
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-359-4773
Provider Business Mailing Address Fax Number:
503-359-3809

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1909 MOUNTAIN VIEW LN
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
FOREST GROVE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97116-2893
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-359-4773
Provider Business Practice Location Address Fax Number:
503-359-3809
Provider Enumeration Date:
06/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  DO23965 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 231406 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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