MEDICARE: GARY LEE THUESON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	MD15092	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043212186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARY LEE THUESON M.D.

Provider Business Mailing Address
First Line	:	PO BOX 979
Second Line	:
City	:	WALDPORT
State	:	OR
Zip	:	97394-0979
Country	:	US
Telephone Number	:	541-563-4833
Fax Number	:	541-563-5233

Provider Business Practice Location Address
First Line	:	525 BAY STREET
Second Line	:
City	:	/WALDPORT
State	:	OR
Zip	:	97394
Country	:	US
Telephone Number	:	541-563-4833
Fax Number	:	541-563-5233

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	01/12/2010

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