Provider Demographics
NPI:1902908171
Name:GAUNTT, KIM GARY (DPM)
Entity Type:Individual
Prefix:MR
First Name:KIM
Middle Name:GARY
Last Name:GAUNTT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 VILLA ROAD
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-1904
Mailing Address - Country:US
Mailing Address - Phone:503-538-0466
Mailing Address - Fax:503-538-0913
Practice Address - Street 1:410 VILLA ROAD
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-1904
Practice Address - Country:US
Practice Address - Phone:503-538-0466
Practice Address - Fax:503-538-0913
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00197213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR001656Medicaid
T92891Medicare UPIN
101888Medicare UPIN
OR101888Medicare ID - Type Unspecified
OR001656Medicaid
OR101887Medicare ID - Type Unspecified