Healthcare Provider Details

I. General information

NPI: 1851587364
Provider Name (Legal Business Name): GRAYDEN WOODRUFF KING D.P.M
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2007
Last Update Date: 12/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

831 NW COUNCIL DR STE 203
GRESHAM OR
97030-3721
US

IV. Provider business mailing address

831 NW COUNCIL DR STE 203
GRESHAM OR
97030-3721
US

V. Phone/Fax

Practice location:
  • Phone: 503-667-6600
  • Fax: 503-667-6608
Mailing address:
  • Phone: 503-667-6600
  • Fax: 503-667-6608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberDP 00436
License Number StateOR

VII. Legacy identifiers

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

# 1
IdentifierR141926
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerMEDICARE PTAN
# 2
Identifier377694002
Identifier TypeMEDICAID
Identifier StateTX
Identifier Issuer
# 3
Identifier377694001
Identifier TypeMEDICAID
Identifier StateTX
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: