Healthcare Provider Details

I. General information

NPI: 1467454165
Provider Name (Legal Business Name): DAVID E GANNETT JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 09/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9205 SW BARNES RD
PORTLAND OR
97225-6603
US

IV. Provider business mailing address

847 NE 19TH AVE SUITE 300
PORTLAND OR
97232-2684
US

V. Phone/Fax

Practice location:
  • Phone: 503-216-2195
  • Fax: 503-216-2196
Mailing address:
  • Phone: 503-963-2801
  • Fax: 503-963-2825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberMD20984
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: