Provider Demographics
NPI:1164435665
Name:GRAY, JEANNIE (OD)
Entity Type:Individual
Prefix:DR
First Name:JEANNIE
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JEANNIE
Other - Middle Name:
Other - Last Name:BURNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:3500 N MIDKIFF RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79705-4834
Mailing Address - Country:US
Mailing Address - Phone:432-699-1300
Mailing Address - Fax:432-694-1981
Practice Address - Street 1:3500 N MIDKIFF RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705-4834
Practice Address - Country:US
Practice Address - Phone:432-699-1300
Practice Address - Fax:432-694-1981
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6390TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX80899QOtherBCBS
TX1614646002Medicaid
TX8F22356Medicare PIN
TX80899QOtherBCBS
TXU96633Medicare UPIN