Provider Demographics
NPI:1003896986
Name:GRAY, BRADFORD CLAYTON (MD)
Entity Type:Individual
Prefix:
First Name:BRADFORD
Middle Name:CLAYTON
Last Name:GRAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 16149
Mailing Address - Street 2:
Mailing Address - City:RUMFORD
Mailing Address - State:RI
Mailing Address - Zip Code:02916-0697
Mailing Address - Country:US
Mailing Address - Phone:401-453-9625
Mailing Address - Fax:401-435-7069
Practice Address - Street 1:19 FRIENDSHIP ST BLDG SUITE240
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02840-2272
Practice Address - Country:US
Practice Address - Phone:401-619-3930
Practice Address - Fax:401-845-1075
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD14900208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ22582OtherBLUE SHIELD
MA0101991Medicaid
MA205717OtherCONNECTICARE
RI1003896986Medicaid
U400225865Medicare PIN
MA205717OtherCONNECTICARE