Provider Demographics
NPI:1427019322
Name:THOMASON, MARY (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:THOMASON
Suffix:
Gender:F
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 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12442 SW SCHOLLS FERRY RD
Practice Address - Street 2:SUITE 106
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-3396
Practice Address - Country:US
Practice Address - Phone:503-216-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42607207R00000X
ORMD27320207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34245500Medicaid
OR212980Medicaid
ORP00604885OtherRR MEDICARE - PHS
WI158750659CMedicare PIN
H86064Medicare UPIN
ORR137633Medicare PIN