Provider Demographics
NPI:1205866399
Name:TABOR, GARETH AUBREY (MD)
Entity Type:Individual
Prefix:
First Name:GARETH
Middle Name:AUBREY
Last Name:TABOR
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 1:27 S STATE ST
Mailing Address - Street 2:SUITE 240
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-3935
Mailing Address - Country:US
Mailing Address - Phone:503-636-9608
Mailing Address - Fax:503-636-9600
Practice Address - Street 1:27 S STATE ST
Practice Address - Street 2:SUITE 240
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-3935
Practice Address - Country:US
Practice Address - Phone:503-636-9608
Practice Address - Fax:503-636-9600
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15143174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR008859Medicaid
OR00WCJQQCMedicare ID - Type Unspecified
OR008859Medicaid