Provider Demographics
NPI:1194019398
Name:GRAY, TASHARA NATASHJA (MD)
Entity Type:Individual
Prefix:DR
First Name:TASHARA
Middle Name:NATASHJA
Last Name:GRAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TASHARA
Other - Middle Name:NATASHJA
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3033 N CENTRAL AVE STE 145
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2808
Mailing Address - Country:US
Mailing Address - Phone:623-583-3001
Mailing Address - Fax:
Practice Address - Street 1:13471 W CORNERSTONE BLVD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2713
Practice Address - Country:US
Practice Address - Phone:480-964-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-06
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL33679208000000X
FLME119054208000000X
AZ61785208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012046900Medicaid