Healthcare Provider Details

I. General information

NPI: 1871102459
Provider Name (Legal Business Name): GREGORY OCHIENG OBALA MBCHB
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2020
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3181 SW SAM JACKSON PARK RD
PORTLAND OR
97239-3011
US

IV. Provider business mailing address

3155 S MOODY AVE APT 501
PORTLAND OR
97239-4733
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-8311
  • Fax:
Mailing address:
  • Phone: 773-630-0781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberPG199923
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: