Provider Demographics
NPI:1346272739
Name:GLORIA, ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:GLORIA
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 3397
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3397
Mailing Address - Country:US
Mailing Address - Phone:503-215-6446
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:171 S HIGHWAY 101
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:OR
Practice Address - Zip Code:97146
Practice Address - Country:US
Practice Address - Phone:503-717-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00038757207Q00000X
ORMD28108207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8257859Medicaid
OR274182Medicaid
WA8257859Medicaid
OR274182Medicaid
ORR157502Medicare PIN
ORR158366Medicare PIN
ORR140938Medicare PIN