MEDICARE: DR. CANDACE LYNN GREGORY DPM

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	213E00000X	Podiatrist	DP00367	OR

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1902813066	OTHER	OR	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1902813066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CANDACE LYNN GREGORY DPM

Provider Business Mailing Address
First Line	:	14795 SW MURRAY SCHOLLS DR STE 121
Second Line	:
City	:	BEAVERTON
State	:	OR
Zip	:	97007-9713
Country	:	US
Telephone Number	:	503-597-5647
Fax Number	:	503-597-5640

Provider Business Practice Location Address
First Line	:	14795 SW MURRAY SCHOLLS DR STE 121
Second Line	:
City	:	BEAVERTON
State	:	OR
Zip	:	97007-9713
Country	:	US
Telephone Number	:	503-597-5647
Fax Number	:	503-597-5640

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

Provider Enumeration Date	:	08/02/2006
Last Update Date	:	08/25/2010

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