Provider Demographics
NPI:1669418810
Name:GROSSNICKLE, DOUGLAS REED (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:REED
Last Name:GROSSNICKLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10113 SE CLEONE CT
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266
Mailing Address - Country:US
Mailing Address - Phone:503-775-7407
Mailing Address - Fax:503-775-1547
Practice Address - Street 1:10373 NE HANCOCK
Practice Address - Street 2:SUITE 219
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220
Practice Address - Country:US
Practice Address - Phone:503-775-7407
Practice Address - Fax:503-775-1547
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD13084207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR264119Medicaid
ORC92776Medicare UPIN
OR264119Medicaid