Provider Demographics
NPI:1083748768
Name:GRAY, CHERYL VANESSA (MD)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:VANESSA
Last Name:GRAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9909 TOPANGA CANYON BLVD
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91311-3602
Mailing Address - Country:US
Mailing Address - Phone:818-426-3473
Mailing Address - Fax:
Practice Address - Street 1:9909 TOPANGA CANYON BLVD
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:CA
Practice Address - Zip Code:91311-3602
Practice Address - Country:US
Practice Address - Phone:818-426-3473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG78007207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A16569Medicare UPIN