1558562496 NPI number — DR. MACEY BRAY D.O.

Table of content: DR. MACEY BRAY D.O. (NPI 1558562496)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558562496 NPI number — DR. MACEY BRAY D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRAY
Provider First Name:
MACEY
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

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:
1558562496
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2019
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGTON
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87499-2019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-325-1572
Provider Business Mailing Address Fax Number:
505-327-4887

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 W MAPLE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARMINGTON
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-272-0011
Provider Business Practice Location Address Fax Number:
505-272-5821
Provider Enumeration Date:
05/29/2007

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: 2085R0202X , with the licence number:  A-1541-10 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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