MEDICARE: DR. TIMOTHY J. GRAY II D.O.

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	DO23965	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	:	1699770057
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIMOTHY J. GRAY II D.O.

Provider Business Mailing Address
First Line	:	PO BOX 189
Second Line	:
City	:	FOREST GROVE
State	:	OR
Zip	:	97116-0189
Country	:	US
Telephone Number	:	503-359-4773
Fax Number	:	503-359-3809

Provider Business Practice Location Address
First Line	:	1909 MOUNTAIN VIEW LN
Second Line	:	SUITE 200
City	:	FOREST GROVE
State	:	OR
Zip	:	97116-2893
Country	:	US
Telephone Number	:	503-359-4773
Fax Number	:	503-359-3809

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

Provider Enumeration Date	:	06/14/2005
Last Update Date	:	07/16/2012

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1909 MOUNTAIN VIEW LN , SUITE 200
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97116-2893

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1909 MOUNTAIN VIEW LN , #200
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97116-2893

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1909 MOUNTAIN VIEW LN , SUITE 200
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1909 MOUNTAIN VIEW LN , SUITE 200
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97116-2893

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1578139309 — SARAH EMELIA MAWDSLEY LPC
Practice Location Address:

1909 MOUNTAIN VIEW LN STE 202
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