Provider Demographics
NPI:1265570741
Name:STILSON, GREGORY HOWARD (DC)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:HOWARD
Last Name:STILSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:GREGORY
Other - Middle Name:HOWARD
Other - Last Name:STILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:7420 SW GARDEN HOME RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-9569
Mailing Address - Country:US
Mailing Address - Phone:503-245-7711
Mailing Address - Fax:
Practice Address - Street 1:7420 SW GARDEN HOME RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-9569
Practice Address - Country:US
Practice Address - Phone:503-245-7711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1320111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000QGBKMMedicare ID - Type Unspecified