1225075559 NPI number — DR. PATRICK ANTHONY GRAY MD

Table of content: DR. PATRICK ANTHONY GRAY MD (NPI 1225075559)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225075559 NPI number — DR. PATRICK ANTHONY GRAY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAY
Provider First Name:
PATRICK
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225075559
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1240 NW 119TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33167-3232
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-685-5688
Provider Business Mailing Address Fax Number:
305-688-7995

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20215 NW 2ND AVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33169-2538
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-652-4542
Provider Business Practice Location Address Fax Number:
305-652-4545
Provider Enumeration Date:
06/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  ME0068131 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 250655601 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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