Healthcare Provider Details

I. General information

NPI: 1124105044
Provider Name (Legal Business Name): GREGORY GULLO MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24076 SE STARK ST SUITE 320
GRESHAM OR
97030-3373
US

IV. Provider business mailing address

24076 SE STARK ST SUITE 320
GRESHAM OR
97030-3373
US

V. Phone/Fax

Practice location:
  • Phone: 503-512-1212
  • Fax: 503-512-1220
Mailing address:
  • Phone: 503-512-1212
  • Fax: 503-512-1220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMD26192
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. GREGORY GULLO
Title or Position: PRESIDENT
Credential: MD
Phone: 503-512-1212