1477585396 NPI number — DR. JASON D GRAY D.P.M.

Table of content: DR. JASON D GRAY D.P.M. (NPI 1477585396)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477585396 NPI number — DR. JASON D GRAY D.P.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAY
Provider First Name:
JASON
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.P.M.
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:
1477585396
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 330
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORTVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46040-0330
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-863-2556
Provider Business Mailing Address Fax Number:
317-203-0420

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 N WABASH AVE STE 460A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46952-2685
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-664-1413
Provider Business Practice Location Address Fax Number:
765-664-2836
Provider Enumeration Date:
07/07/2006

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: 213ES0103X , with the licence number:  07000998A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5324290006 . This is a "DME MC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200535890 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5324290003 . This is a "DME ES" identifier . This identifiers is of the category "OTHER".
  • Identifier: 532490004 . This is a "DME BR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5324290007 . This is a "DME WV" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5324290008 . This is a "DME FC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4324290005 . This is a "DME AC" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00219222 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".




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