Gresham Internal Medicine Clinic

NPI #1134204340 in Gresham, Oregon

Provider Information

NPI Number: 1134204340
Entity Type: Organization
Organization Name: Gresham Internal Medicine Clinic
Primary Specialty: Internal Medicine
Enumeration Date: Oct 26, 2006
Last Updated: Dec 11, 2008

Practice Location

Address: 24900 SE STARK ST STE 109
City: Gresham
State: Oregon
ZIP Code: 97030-3381
Phone: (503) 667-1015

Authorized Official

Name: DR. JOHN M CUSTIS, MD
Title: OWNER/PARTNER
Phone: (503) 667-1015

Specialties & Taxonomy Codes

Specialty	Taxonomy Code	Primary
Internal Medicine	207R00000X	Primary

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