Provider Demographics
NPI:1467454181
Name:IRVINE, GREGORY W (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:W
Last Name:IRVINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15755 SW SEQUOIA PKWY
Mailing Address - Street 2:STE 200
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7166
Mailing Address - Country:US
Mailing Address - Phone:503-639-6002
Mailing Address - Fax:503-639-1403
Practice Address - Street 1:15755 SW SEQUOIA PKWY
Practice Address - Street 2:STE 200
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-7166
Practice Address - Country:US
Practice Address - Phone:503-639-6002
Practice Address - Fax:503-639-1403
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD14549207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR139550Medicaid
ORC94209Medicare UPIN
OR139550Medicaid
OR106491Medicare PIN