Provider Demographics
NPI:1326014234
Name:GREWE, GWEN JOHANNA (MD)
Entity type:Individual
Prefix:MRS
First Name:GWEN
Middle Name:JOHANNA
Last Name:GREWE
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 1:2007 SW DEWITT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-2031
Mailing Address - Country:US
Mailing Address - Phone:503-977-2070
Mailing Address - Fax:
Practice Address - Street 1:19875 SW 65TH AVE
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-8353
Practice Address - Country:US
Practice Address - Phone:503-692-7785
Practice Address - Fax:503-885-1663
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21373207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR288449Medicaid
OR288449Medicaid
ORH20190Medicare UPIN