Provider Demographics
NPI:1417941600
Name:WILLIS, GREGORY S (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:S
Last Name:WILLIS
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 1:6489 SW BORLAND RD
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-9798
Mailing Address - Country:US
Mailing Address - Phone:503-692-4843
Mailing Address - Fax:503-692-6543
Practice Address - Street 1:6489 SW BORLAND RD
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-9798
Practice Address - Country:US
Practice Address - Phone:503-692-4843
Practice Address - Fax:503-692-6543
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD280192085R0001X, 2471R0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No2471R0002XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiation Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR033138015OtherREGENCE BCBS
OR140838OtherMEDICARE PTAN
OR140838OtherMEDICARE PTAN
OR033138015OtherREGENCE BCBS