Provider Demographics
NPI:1043212186
Name:THUESON, GARY LEE (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:LEE
Last Name:THUESON
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:PO BOX 979
Mailing Address - Street 2:
Mailing Address - City:WALDPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97394-0979
Mailing Address - Country:US
Mailing Address - Phone:541-563-4833
Mailing Address - Fax:541-563-5233
Practice Address - Street 1:525 BAY STREET
Practice Address - Street 2:
Practice Address - City:/WALDPORT
Practice Address - State:OR
Practice Address - Zip Code:97394
Practice Address - Country:US
Practice Address - Phone:541-563-4833
Practice Address - Fax:541-563-5233
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15092207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR148304Medicaid
A37438Medicare ID - Type Unspecified
OR148304Medicaid