Provider Demographics
NPI:1396727400
Name:GERRY, JEFFREY IRA (MDPHD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:IRA
Last Name:GERRY
Suffix:
Gender:M
Credentials:MDPHD
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 821350
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-0030
Mailing Address - Country:US
Mailing Address - Phone:503-283-5220
Mailing Address - Fax:503-283-9527
Practice Address - Street 1:9155 SW BARNES RD
Practice Address - Street 2:STE 204
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6625
Practice Address - Country:US
Practice Address - Phone:503-297-7463
Practice Address - Fax:503-297-8835
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD16613208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR010350Medicaid
OR018132001OtherBLUE CROSS
WA1057847Medicaid
E68722Medicare UPIN
OR00WCPHWBMedicare ID - Type Unspecified