Provider Demographics
NPI:1073802062
Name:BURNETT, GREGORY PAUL (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:PAUL
Last Name:BURNETT
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 1:10201 SE MAIN ST STE 10
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2937
Mailing Address - Country:US
Mailing Address - Phone:503-255-2186
Mailing Address - Fax:
Practice Address - Street 1:10201 SE MAIN ST STE 10
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216
Practice Address - Country:US
Practice Address - Phone:503-255-2186
Practice Address - Fax:503-255-2194
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-31
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORMD167544207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program