Healthcare Provider Details

I. General information

NPI: 1861755126
Provider Name (Legal Business Name): CRAIG THOMAS GILLIS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 05/18/2020
Certification Date: 05/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4103 MERCANTILE DR
LAKE OSWEGO OR
97035
US

IV. Provider business mailing address

4103 MERCANTILE DR
LAKE OSWEGO OR
97035-2556
US

V. Phone/Fax

Practice location:
  • Phone: 503-850-9940
  • Fax: 503-850-6709
Mailing address:
  • Phone: 503-850-9940
  • Fax: 503-850-6709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberDO193270
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberPG157927
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License NumberDO193270
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: