Provider Demographics
NPI:1922243518
Name:GRAY, MATTHEW (LMT)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:GRAY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2718 SW FAIRVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-5825
Mailing Address - Country:US
Mailing Address - Phone:503-709-5898
Mailing Address - Fax:
Practice Address - Street 1:3944 N MISSISSIPPI AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1163
Practice Address - Country:US
Practice Address - Phone:503-517-8222
Practice Address - Fax:503-517-8223
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11368172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker