Provider Demographics
NPI:1881697415
Name:TAKAHASHI, GARY W (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:W
Last Name:TAKAHASHI
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 3378
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3378
Mailing Address - Country:US
Mailing Address - Phone:503-203-1000
Mailing Address - Fax:503-203-1010
Practice Address - Street 1:15700 SW GREYSTONE COURT
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-6011
Practice Address - Country:US
Practice Address - Phone:503-203-1000
Practice Address - Fax:503-203-1010
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD14500207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORCV0082OtherRR MEDICARE GROUP NUMBER
OR00WFBBCCOtherMEDICARE ID
OR54853Medicaid
OR54853Medicaid