Basic Information
| Provider Information | |||||||||
| NPI: | 1417941600 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIS | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6489 SW BORLAND RD | ||||||||
| Address2: | |||||||||
| City: | TUALATIN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970629798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036924843 | ||||||||
| FaxNumber: | 5036926543 | ||||||||
| Practice Location | |||||||||
| Address1: | 6489 SW BORLAND RD | ||||||||
| Address2: | |||||||||
| City: | TUALATIN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970629798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036924843 | ||||||||
| FaxNumber: | 5036926543 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2005 | ||||||||
| LastUpdateDate: | 07/16/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | MD28019 | OR | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2471R0002X | MD28019 | OR | N | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Radiation Therapy |
ID Information
| ID | Type | State | Issuer | Description | 033138015 | 01 | OR | REGENCE BCBS | OTHER | 140838 | 01 | OR | MEDICARE PTAN | OTHER |