Provider Demographics
NPI:1083067839
Name:GREY, JASON MICHAEL (CMP)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:MICHAEL
Last Name:GREY
Suffix:
Gender:M
Credentials:CMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:388 WINDERMERE BLVD
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-2823
Mailing Address - Country:US
Mailing Address - Phone:716-907-2853
Mailing Address - Fax:
Practice Address - Street 1:1515 KENSINGTON AVE
Practice Address - Street 2:10
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-1436
Practice Address - Country:US
Practice Address - Phone:716-235-3252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25GR1400966211D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes211D00000XPodiatric Medicine & Surgery Service ProvidersAssistant, Podiatric