Provider Demographics
NPI:1275770349
Name:K G GAUNTT DPM PC
Entity Type:Organization
Organization Name:K G GAUNTT DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:GAUNTT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:503-538-0466
Mailing Address - Street 1:410 VILLA ROAD
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132
Mailing Address - Country:US
Mailing Address - Phone:503-538-0466
Mailing Address - Fax:503-538-0913
Practice Address - Street 1:410 VILLA ROAD
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132
Practice Address - Country:US
Practice Address - Phone:503-538-0466
Practice Address - Fax:503-538-0913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-12
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00197213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR001656Medicaid
OR101887Medicare UPIN
OR001656Medicaid