Provider Demographics
NPI:1295013613
Name:RICHARD, GREGORY ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ALLEN
Last Name:RICHARD
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 1:444 NW ELKS DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3745
Mailing Address - Country:US
Mailing Address - Phone:541-754-1271
Mailing Address - Fax:
Practice Address - Street 1:444 NW ELKS DR
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330
Practice Address - Country:US
Practice Address - Phone:541-754-1150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-02
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.207614207W00000X
MST-2480207W00000X
ORMD186395207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA400079ZM9MMedicare PIN