1033259734 NPI number — DR. CORNELIUS JEROME GEHRED DDS

Table of content: DR. CORNELIUS JEROME GEHRED DDS (NPI 1033259734)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033259734 NPI number — DR. CORNELIUS JEROME GEHRED DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GEHRED
Provider First Name:
CORNELIUS
Provider Middle Name:
JEROME
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
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:
1033259734
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10340 SE DIVISION ST STE 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97266-1269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-256-3199
Provider Business Mailing Address Fax Number:
503-256-9383

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2010 BOTULPH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA FE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-983-1312
Provider Business Practice Location Address Fax Number:
505-983-8170
Provider Enumeration Date:
02/08/2007

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: 1223G0001X , with the licence number:  D9242 , 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)





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