Provider Demographics
NPI:1477518694
Name:TIMOTHY J GRAY DO LLC
Entity Type:Organization
Organization Name:TIMOTHY J GRAY DO LLC
Other - Org Name:MOUNTAIN VIEW MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:SR
Authorized Official - Credentials:DO
Authorized Official - Phone:503-359-4773
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-0189
Mailing Address - Country:US
Mailing Address - Phone:503-359-4773
Mailing Address - Fax:503-359-3809
Practice Address - Street 1:1909 MOUNTAIN VIEW LN
Practice Address - Street 2:#200
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-2893
Practice Address - Country:US
Practice Address - Phone:503-359-4773
Practice Address - Fax:503-359-3809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022891Medicaid
OR022891Medicaid