Provider Demographics
NPI:1770522690
Name:LACKIDES, GREGORY A (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:LACKIDES
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 8100
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97303-0900
Mailing Address - Country:US
Mailing Address - Phone:503-399-2424
Mailing Address - Fax:503-375-7429
Practice Address - Street 1:2020 CAPITOL ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97303-3244
Practice Address - Country:US
Practice Address - Phone:503-399-2424
Practice Address - Fax:503-375-7429
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD151219207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CS4159OtherRAILROAD GROUP
080132461OtherRAILROAD MEDICARE
OR151219Medicaid
OR151219Medicaid
ORR101916Medicare PIN
080132461OtherRAILROAD MEDICARE