Provider Demographics
NPI:1144220765
Name:GRAGNOLA, THOMAS G (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:G
Last Name:GRAGNOLA
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 1:9555 SW BARNES RD SUITE 255
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225
Mailing Address - Country:US
Mailing Address - Phone:503-902-1590
Mailing Address - Fax:503-723-2862
Practice Address - Street 1:9555 SW BARNES RD SUITE 255
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225
Practice Address - Country:US
Practice Address - Phone:503-902-1590
Practice Address - Fax:503-723-2862
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD20503207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150544Medicaid
G50082Medicare UPIN
ORR113098Medicare PIN