Provider Demographics
NPI:1235172743
Name:MOE, GORDON H (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:H
Last Name:MOE
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:PO BOX 8100
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97303-0900
Mailing Address - Country:US
Mailing Address - Phone:503-399-2424
Mailing Address - Fax:503-375-7429
Practice Address - Street 1:2020 CAPITOL ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97303-3244
Practice Address - Country:US
Practice Address - Phone:503-399-2424
Practice Address - Fax:503-375-7429
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD220855208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR220855Medicaid
020020350OtherRAILROAD MEDICARE
CS4159OtherRAILROAD GROUP
020020350OtherRAILROAD MEDICARE
OR220855Medicaid
OR1228590005Medicare NSC