Provider Demographics
NPI:1376104505
Name:FILLMORE, GREGORY D (DC)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:D
Last Name:FILLMORE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:736 SE 60TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-1906
Mailing Address - Country:US
Mailing Address - Phone:971-308-9155
Mailing Address - Fax:971-206-6531
Practice Address - Street 1:736 SE 60TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-1906
Practice Address - Country:US
Practice Address - Phone:971-308-9155
Practice Address - Fax:971-206-6531
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-27
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6007111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor