Provider Demographics
NPI:1295915098
Name:GARETH A. TABOR M.D., P.C
Entity type:Organization
Organization Name:GARETH A. TABOR M.D., P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:TABOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-636-9608
Mailing Address - Street 1:27 S STATE ST
Mailing Address - Street 2:#240
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-3935
Mailing Address - Country:US
Mailing Address - Phone:503-636-9608
Mailing Address - Fax:503-636-9600
Practice Address - Street 1:27 S STATE ST
Practice Address - Street 2:#240
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-3935
Practice Address - Country:US
Practice Address - Phone:503-636-9608
Practice Address - Fax:503-636-9600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15143174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR008859Medicaid
OR1205866399OtherNPI FOR DR. TABOR
OR1205866399OtherNPI FOR DR. TABOR