Provider Demographics
NPI:1073555009
Name:GRAY, GARY R (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:R
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 1:1516 COTNER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-3303
Mailing Address - Country:US
Mailing Address - Phone:310-445-2951
Mailing Address - Fax:310-479-1459
Practice Address - Street 1:1516 COTNER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-3303
Practice Address - Country:US
Practice Address - Phone:310-445-2951
Practice Address - Fax:310-479-1459
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA242262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A242260OtherBLUE SHIELD
CAP00408987OtherRAILROAD MEDICARE - MDI
CA00A242260Medicaid
CAGR0106037Medicaid
CAAQ200YMedicare PIN
CAGR0106037Medicaid
CAWA24226AMedicare PIN
CAWA44672CMedicare PIN
CAP00408987OtherRAILROAD MEDICARE - MDI
CAAQ200ZMedicare PIN