Provider Demographics
NPI:1851587364
Name:KING, GRAYDEN WOODRUFF (DPM)
Entity Type:Individual
Prefix:DR
First Name:GRAYDEN
Middle Name:WOODRUFF
Last Name:KING
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:831 NW COUNCIL DR
Mailing Address - Street 2:STE 203
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-3721
Mailing Address - Country:US
Mailing Address - Phone:503-667-6600
Mailing Address - Fax:503-667-6608
Practice Address - Street 1:831 NW COUNCIL DR
Practice Address - Street 2:STE 203
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3721
Practice Address - Country:US
Practice Address - Phone:503-667-6600
Practice Address - Fax:503-667-6608
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-18
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP 00436213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR141926OtherMEDICARE PTAN
TX377694002Medicaid
TX377694001Medicaid