Provider Demographics
NPI:1205362944
Name:DEGRAVELLE, GINGER L (MD)
Entity Type:Individual
Prefix:
First Name:GINGER
Middle Name:L
Last Name:DEGRAVELLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 SE MAIN ST STE 112
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2441
Mailing Address - Country:US
Mailing Address - Phone:503-255-3054
Mailing Address - Fax:
Practice Address - Street 1:10000 SE MAIN ST STE 112
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2441
Practice Address - Country:US
Practice Address - Phone:503-255-3054
Practice Address - Fax:503-255-7651
Is Sole Proprietor?:No
Enumeration Date:2017-05-01
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD217089207RG0100X, 207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program