Healthcare Provider Details

I. General information

NPI: 1477555860
Provider Name (Legal Business Name): PETER R GYERKO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 04/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24988 SE STARK ST SUITE 200
GRESHAM OR
97030-8322
US

IV. Provider business mailing address

15455 NW GREENBRIER PKWY STE 112
BEAVERTON OR
97006-7374
US

V. Phone/Fax

Practice location:
  • Phone: 503-667-8878
  • Fax: 503-667-0310
Mailing address:
  • Phone: 503-466-1668
  • Fax: 503-439-6194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD15333
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: