1518043348 NPI number — J BRIAN GRAY OD PA

Table of content: (NPI 1518043348)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518043348 NPI number — J BRIAN GRAY OD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
J BRIAN GRAY OD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1518043348
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
114 E OAK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72401-3561
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-935-5454
Provider Business Mailing Address Fax Number:
870-935-2643

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
114 E OAK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72401-3561
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-935-5454
Provider Business Practice Location Address Fax Number:
870-935-2643
Provider Enumeration Date:
10/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRAY
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
BRIAN
Authorized Official Title or Position:
DOCTOR/OWNER
Authorized Official Telephone Number:
870-935-5454

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  AR2414 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152WC0802X , with the licence number: AR2414 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WL0500X , with the licence number: AR2414 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WP0200X , with the licence number: AR2414 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WS0006X , with the licence number: AR2414 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WX0102X , with the licence number: AR2414 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 42186 . This is a "DAVIS VISION" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 149197722 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 12189 . This is a "SPECTERA" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 123724722 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 48741 . This is a "INDIVIDUAL BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 207398 . This is a "EYEMED" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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