Provider Demographics
NPI:1043731557
Name:GRAY, JOSEPH M (OD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:M
Last Name:GRAY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:795 E. SECOND ST.
Mailing Address - Street 2:SUITE 2
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-2007
Mailing Address - Country:US
Mailing Address - Phone:909-706-3899
Mailing Address - Fax:909-864-5228
Practice Address - Street 1:795 E. SECOND ST.
Practice Address - Street 2:SUITE 2
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766
Practice Address - Country:US
Practice Address - Phone:909-706-3899
Practice Address - Fax:909-469-8640
Is Sole Proprietor?:No
Enumeration Date:2017-07-06
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN3589152W00000X
CAOPT34165-TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist