Provider Demographics
NPI:1699701227
Name:BANKS, GORDON EARL (PHD,MD)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:EARL
Last Name:BANKS
Suffix:
Gender:M
Credentials:PHD,MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 SE STRATUS AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-6255
Mailing Address - Country:US
Mailing Address - Phone:503-434-6090
Mailing Address - Fax:503-474-3306
Practice Address - Street 1:2700 SE STRATUS AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6255
Practice Address - Country:US
Practice Address - Phone:503-434-6090
Practice Address - Fax:503-474-3306
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21516174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR603273000OtherUS DEPARTMENT OF LABOR
OR130022916OtherRAILROAD MEDICARE
OR134029Medicaid
OR134029Medicaid
OR603273000OtherUS DEPARTMENT OF LABOR