Provider Demographics
NPI:1588650279
Name:LINDQUIST, GRANT R (MD)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:R
Last Name:LINDQUIST
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 1:6420 S MACADAM AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3517
Mailing Address - Country:US
Mailing Address - Phone:503-244-8601
Mailing Address - Fax:503-244-3013
Practice Address - Street 1:19250 SW 65TH AVE
Practice Address - Street 2:SUITE 215
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7452
Practice Address - Country:US
Practice Address - Phone:503-692-3630
Practice Address - Fax:503-692-3420
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2020-08-13
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-04-13
Provider Licenses
StateLicense IDTaxonomies
ORMD13176207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR215368Medicaid
OR215368Medicaid
OR180006810OtherRAILROAD MEDICARE
ORR151920Medicare PIN
OR215368Medicaid