Provider Demographics
NPI:1922080480
Name:GREGORY, KENTON W (MD)
Entity Type:Individual
Prefix:
First Name:KENTON
Middle Name:W
Last Name:GREGORY
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:PO BOX 821350
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-0030
Mailing Address - Country:US
Mailing Address - Phone:503-283-5220
Mailing Address - Fax:503-283-9527
Practice Address - Street 1:9155 SW BARNES RD
Practice Address - Street 2:#204
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6625
Practice Address - Country:US
Practice Address - Phone:503-297-0541
Practice Address - Fax:503-216-4079
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD17161207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR029749Medicaid
OR029749Medicaid
A92589Medicare UPIN