Provider Demographics
NPI:1063465391
Name:GRAY, KEITH (OD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:GRAY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1299 SOUTHLAND MALL
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38116-7807
Mailing Address - Country:US
Mailing Address - Phone:901-396-3742
Mailing Address - Fax:901-396-9744
Practice Address - Street 1:1299 SOUTHLAND MALL
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-7807
Practice Address - Country:US
Practice Address - Phone:901-396-3742
Practice Address - Fax:901-396-9744
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1153DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4118471OtherBCBS
TN21873Medicaid
TN21873Medicaid