Provider Demographics
NPI:1275521601
Name:GRAY, SCOTT KEVIN (DPM)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:KEVIN
Last Name:GRAY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8604 DOLLARWAY RD
Mailing Address - Street 2:
Mailing Address - City:WHITE HALL
Mailing Address - State:AR
Mailing Address - Zip Code:71602-2814
Mailing Address - Country:US
Mailing Address - Phone:870-536-3669
Mailing Address - Fax:870-536-0149
Practice Address - Street 1:8604 DOLLARWAY RD
Practice Address - Street 2:
Practice Address - City:WHITE HALL
Practice Address - State:AR
Practice Address - Zip Code:71602-2814
Practice Address - Country:US
Practice Address - Phone:870-536-3669
Practice Address - Fax:870-536-0149
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR197213ES0103X
TX1597213ES0103X
OK218213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5W846OtherBLUE CROSS & BLUE SHIELD
AR146570717Medicaid
AR4666670001Medicare NSC
TX00811PMedicare PIN
AR5W846OtherBLUE CROSS & BLUE SHIELD
U89815Medicare UPIN
AR5W846Medicare PIN