Provider Demographics
NPI:1093823379
Name:GRAYSON, ROBERT W (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:GRAYSON
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 1:7030 NEW SANGER AVE
Mailing Address - Street 2:STE 204
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712
Mailing Address - Country:US
Mailing Address - Phone:254-753-3190
Mailing Address - Fax:254-755-8515
Practice Address - Street 1:7030 NEW SANGER AVE
Practice Address - Street 2:STE 204
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712
Practice Address - Country:US
Practice Address - Phone:254-753-3190
Practice Address - Fax:254-755-8515
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE2581207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114207702Medicaid
TX114207702Medicaid