1205815610 NPI number — CARRIE DIANE GRAY M.P.T.

Table of content: CARRIE DIANE GRAY M.P.T. (NPI 1205815610)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205815610 NPI number — CARRIE DIANE GRAY M.P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAY
Provider First Name:
CARRIE
Provider Middle Name:
DIANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DOERKSEN
Provider Other First Name:
CARRIE
Provider Other Middle Name:
DIANE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.P.T.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1205815610
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2475 BOARDWALK
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORMAN
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73069-6332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-447-1991
Provider Business Mailing Address Fax Number:
405-447-1198

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2340 NW 32ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWCASTLE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73065-6589
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-392-3322
Provider Business Practice Location Address Fax Number:
405-392-3356
Provider Enumeration Date:
01/13/2006

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: 225100000X , with the licence number:  PT3813 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200121360A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com