Provider Demographics
NPI:1790760791
Name:TRUPP, GARY J (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:J
Last Name:TRUPP
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 1:620 NW 11TH ST STE M201
Mailing Address - Street 2:
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-6941
Mailing Address - Country:US
Mailing Address - Phone:541-289-4118
Mailing Address - Fax:541-667-3484
Practice Address - Street 1:620 NW 11TH ST STE M106
Practice Address - Street 2:
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-6941
Practice Address - Country:US
Practice Address - Phone:541-667-3801
Practice Address - Fax:541-667-3802
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22618207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR288161Medicaid
ORD72510Medicare UPIN
OR288161Medicaid