Provider Demographics
NPI:1144390592
Name:GAMELIN, LARA JAE (MD)
Entity type:Individual
Prefix:DR
First Name:LARA
Middle Name:JAE
Last Name:GAMELIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2400 NW KINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3900
Mailing Address - Country:US
Mailing Address - Phone:541-757-2400
Mailing Address - Fax:541-752-0931
Practice Address - Street 1:2400 NW KINGS BLVD
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3900
Practice Address - Country:US
Practice Address - Phone:541-757-2400
Practice Address - Fax:541-752-0931
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD19740207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR931288530OtherTAX OR BUSINESS ID NUMBER
OR078225Medicaid
ORG22564Medicare UPIN
OR078225Medicaid