Provider Demographics
NPI:1588688014
Name:CARROLL, GREGORY S (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:S
Last Name:CARROLL
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 1:10250 SW GREENBURG RD
Mailing Address - Street 2:4 LINCOLN CENTER, SUITE 125
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-5470
Mailing Address - Country:US
Mailing Address - Phone:503-719-6783
Mailing Address - Fax:971-327-6734
Practice Address - Street 1:10250 SW GREENBURG RD
Practice Address - Street 2:4 LINCOLN CENTER, SUITE 125
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-5470
Practice Address - Country:US
Practice Address - Phone:503-719-6783
Practice Address - Fax:971-327-6734
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26081207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR005705Medicaid
OR005705Medicaid
H02136Medicare UPIN