Provider Demographics
NPI:1225266745
Name:GRAY, JACK GIBSON (DO)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:GIBSON
Last Name:GRAY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 TAMERLANE
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-2700
Mailing Address - Country:US
Mailing Address - Phone:404-771-4665
Mailing Address - Fax:
Practice Address - Street 1:135 TAMERLANE
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-2700
Practice Address - Country:US
Practice Address - Phone:404-771-4665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0729042080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine