Provider Demographics
NPI:1578593448
Name:INGRAM, GARY LOHRENZ (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LOHRENZ
Last Name:INGRAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 H EAST BARNETT ROAD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8383
Mailing Address - Country:US
Mailing Address - Phone:541-773-7273
Mailing Address - Fax:541-773-2027
Practice Address - Street 1:2620 H EAST BARNETT ROAD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8383
Practice Address - Country:US
Practice Address - Phone:541-773-7273
Practice Address - Fax:541-773-2027
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10428207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR093617Medicaid
OR093617Medicaid
D72930Medicare UPIN