1124324744 NPI number — MELANIE GRAY D.O.

Table of content: MELANIE GRAY D.O. (NPI 1124324744)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124324744 NPI number — MELANIE GRAY D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAY
Provider First Name:
MELANIE
Provider Middle Name:
Provider Name Prefix Text:
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:
1124324744
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/02/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 W CANNON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76104-3029
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-877-5858
Provider Business Mailing Address Fax Number:
817-335-4418

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3101 CHURCHILL DR STE 115
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLOWER MOUND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75022-2717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-645-1804
Provider Business Practice Location Address Fax Number:
817-725-7885
Provider Enumeration Date:
01/28/2011

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: 207Q00000X , with the licence number:  P9861 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 354166601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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