Provider Demographics
NPI:1932344199
Name:GRAY, CHRISTINE (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
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 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:
Practice Address - Street 1:16180 SE SUNNYSIDE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97015-6301
Practice Address - Country:US
Practice Address - Phone:503-582-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-02
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLL17978207Q00000X
ORMD153563207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500635615Medicaid
OR500635615Medicaid
ORR163101Medicare PIN
ORR163103Medicare PIN
ORR163104Medicare PIN
ORR163105Medicare PIN
ORR163106Medicare PIN