Provider Demographics
NPI:1528004462
Name:GILMORE, PHYLLIS C (MD)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:C
Last Name:GILMORE
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 1:18610 NW CORNELL RD
Practice Address - Street 2:SUITE 101
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-9204
Practice Address - Country:US
Practice Address - Phone:503-216-9360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23420207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00468705OtherRR MEDICARE
ORP00468705OtherRR MEDICARE