Provider Demographics
NPI:1174898373
Name:GRAY, THOMAS CHRISTOPHER
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:CHRISTOPHER
Last Name:GRAY
Suffix:
Gender:M
Credentials:
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 189
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-0189
Mailing Address - Country:US
Mailing Address - Phone:503-359-4773
Mailing Address - Fax:
Practice Address - Street 1:4660 NE BELKNAP CT
Practice Address - Street 2:SUITE 119
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-6467
Practice Address - Country:US
Practice Address - Phone:503-359-4773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-21
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO16653207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500720355Medicaid
OR500720355Medicaid