Provider Demographics
NPI:1376585448
Name:THOMAS, GREGORY M (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:M
Last Name:THOMAS
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 20130
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97307-0130
Mailing Address - Country:US
Mailing Address - Phone:503-393-2533
Mailing Address - Fax:503-393-5978
Practice Address - Street 1:5100 RIVER RD N
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-5371
Practice Address - Country:US
Practice Address - Phone:503-393-2533
Practice Address - Fax:503-393-5978
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13584207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
R157127OtherMEDICARE PTAN
OR283663Medicaid
ORC93924Medicare UPIN