# GRESHAM INTERNAL MEDICINE CLINIC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1134204340
- **Authorized official:** DR. JOHN M CUSTIS MD (OWNER/PARTNER)
- **Authorized official phone:** (503) 667-1015

## Contact information

- **Practice address:** 24900 SE STARK ST STE 109, GRESHAM, OR 97030-3381
- **Practice address phone:** (503) 667-1015
- **Practice address fax:** (503) 667-0406
- **Mailing address:** PO BOX 23200, PORTLAND, OR 97281-3200
- **Mailing address phone:** (503) 667-1015
- **Mailing address fax:** (503) 667-0406

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207R00000X | Internal Medicine Physician | 01794 | OR | Yes |

## Other

- **Enumeration date:** 10/26/2006
- **Last updated:** 12/11/2008