Basic Information
| Provider Information | |||||||||
| NPI: | 1356317150 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4411 SW VERMONT ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972191020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034949992 | ||||||||
| FaxNumber: | 5034941967 | ||||||||
| Practice Location | |||||||||
| Address1: | 4855 SW WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | BEAVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970053460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038132000 | ||||||||
| FaxNumber: | 5036264149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 08/18/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD169520 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 011180781 | 05 | PA | MEDICAID |