Provider Demographics
NPI:1063589026
Name:GULLO, GEOFFREY M (MD)
Entity type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:M
Last Name:GULLO
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 28130
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97228-8130
Mailing Address - Country:US
Mailing Address - Phone:503-681-1109
Mailing Address - Fax:503-681-1835
Practice Address - Street 1:335 SE 8TH AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4246
Practice Address - Country:US
Practice Address - Phone:513-681-1109
Practice Address - Fax:503-681-1835
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD245152085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227540Medicaid
G95934Medicare UPIN
ORR147312Medicare PIN
ORP00733972Medicare PIN
OR227540Medicaid
ORG95934Medicare UPIN