Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | DO09109 | OR |
NPI | 1003810441 |
---|---|
Provider Name | Dr. Timothy J. Gray SR. |
First Address | Forest Grove, OR 97116-0189 |
Second Address | Forest Grove, OR 97116-2893 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/06/2005 |
Last Update Date | 04/05/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
235168 | (05) | OR |
C91309 | (02) | OR |