Provider Demographics
NPI:1902813066
Name:GREGORY, CANDACE LYNN (DPM)
Entity Type:Individual
Prefix:DR
First Name:CANDACE
Middle Name:LYNN
Last Name:GREGORY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14795 SW MURRAY SCHOLLS DR STE 121
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-9713
Mailing Address - Country:US
Mailing Address - Phone:503-597-5647
Mailing Address - Fax:503-597-5640
Practice Address - Street 1:14795 SW MURRAY SCHOLLS DR STE 121
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007-9713
Practice Address - Country:US
Practice Address - Phone:503-597-5647
Practice Address - Fax:503-597-5640
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00367213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1902813066OtherRAILROAD MEDICARE
OR1902813066OtherRAILROAD MEDICARE
R133460Medicare ID - Type Unspecified
V07714Medicare UPIN