Provider Demographics
NPI:1104392679
Name:GRAY DERM PLLC
Entity Type:Organization
Organization Name:GRAY DERM PLLC
Other - Org Name:GRAY DERM LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:614-596-6789
Mailing Address - Street 1:1272 HUNTER AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43201-3231
Mailing Address - Country:US
Mailing Address - Phone:614-596-6789
Mailing Address - Fax:
Practice Address - Street 1:525 N EASTOWN RD STE A
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45807-2268
Practice Address - Country:US
Practice Address - Phone:419-998-8297
Practice Address - Fax:419-226-8309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-22
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH34.013501OtherOH LICENSE
MI5101021720OtherMI LICENSE