Healthcare Provider Details

I. General information

NPI: 1811951148
Provider Name (Legal Business Name): MURLAN E GRISE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

831 NW COUNCIL DR STE 125
GRESHAM OR
97030-3794
US

IV. Provider business mailing address

831 NW COUNCIL DR STE 125
GRESHAM OR
97030-3794
US

V. Phone/Fax

Practice location:
  • Phone: 503-665-8176
  • Fax: 503-665-8178
Mailing address:
  • Phone: 503-665-8176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO13497
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier290957
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: