Provider Demographics
NPI:1255326088
Name:RAY, JOHN ROGER (DO)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ROGER
Last Name:RAY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:RR 103 SUPPLY STREET, PO BOX 507
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:WV
Mailing Address - Zip Code:24836-0507
Mailing Address - Country:US
Mailing Address - Phone:304-448-2101
Mailing Address - Fax:304-448-3217
Practice Address - Street 1:RR 103 SUPPLY STREET
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:WV
Practice Address - Zip Code:24836-0507
Practice Address - Country:US
Practice Address - Phone:304-448-2101
Practice Address - Fax:304-448-3217
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1093207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001720284OtherBLUE CROSS/BLUE SHIELD
WV0071227000Medicaid
WV550674700OtherSTATE TAX DEPARTMENT
WV0071227000Medicaid
WV0601332Medicare ID - Type Unspecified
WV2034772Medicare PIN
WVE05905Medicare UPIN