Provider Demographics
NPI:1568412351
Name:KING, GERALD MARLIN (DO)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:MARLIN
Last Name:KING
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 PORTLAND AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:GLADSTONE
Mailing Address - State:OR
Mailing Address - Zip Code:97027-2170
Mailing Address - Country:US
Mailing Address - Phone:503-655-2404
Mailing Address - Fax:503-655-1581
Practice Address - Street 1:1105 PORTLAND AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:GLADSTONE
Practice Address - State:OR
Practice Address - Zip Code:97027-2170
Practice Address - Country:US
Practice Address - Phone:503-655-2404
Practice Address - Fax:503-655-1581
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11183207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR059543Medicaid
F03444Medicare UPIN
R0000BHNCXMedicare ID - Type Unspecified