Provider Demographics
NPI:1639394075
Name:GRITZKA, THOMAS LEHMAN (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:LEHMAN
Last Name:GRITZKA
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 1:2100 SE LAKE RD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-7759
Mailing Address - Country:US
Mailing Address - Phone:503-659-6611
Mailing Address - Fax:
Practice Address - Street 1:2100 SE LAKE RD
Practice Address - Street 2:SUITE 6
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-7759
Practice Address - Country:US
Practice Address - Phone:503-659-6611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD08117174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORE41471Medicare UPIN