Provider Demographics
NPI:1124075791
Name:GULLO, GREGORY (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
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 1:2020 8TH AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-4657
Mailing Address - Country:US
Mailing Address - Phone:503-512-1212
Mailing Address - Fax:503-512-1220
Practice Address - Street 1:2020 8TH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-4657
Practice Address - Country:US
Practice Address - Phone:503-512-1212
Practice Address - Fax:503-512-1220
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26192207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR027890Medicaid
OR132591Medicare ID - Type UnspecifiedMEDICAER NUMBER
OR027890Medicaid