Provider Demographics
NPI:1033163027
Name:GILLINGHAM, TODD S (MD)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:S
Last Name:GILLINGHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17200 NW CORRIDOR CT STE 110
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-3295
Mailing Address - Country:US
Mailing Address - Phone:503-614-8633
Mailing Address - Fax:503-614-8635
Practice Address - Street 1:17200 NW CORRIDOR CT STE 110
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-3295
Practice Address - Country:US
Practice Address - Phone:503-614-8633
Practice Address - Fax:503-614-8635
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2025-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22422207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR288258Medicaid
OR288258Medicaid
ORG41376Medicare UPIN