Provider Demographics
NPI:1275582272
Name:GRAY, WOODROW WILSON JR (MD PHD)
Entity Type:Individual
Prefix:
First Name:WOODROW
Middle Name:WILSON
Last Name:GRAY
Suffix:JR
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 PINE ST
Mailing Address - Street 2:SUITE 910
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201
Mailing Address - Country:US
Mailing Address - Phone:478-742-0059
Mailing Address - Fax:478-746-3086
Practice Address - Street 1:840 PINE ST
Practice Address - Street 2:SUITE 910
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201
Practice Address - Country:US
Practice Address - Phone:478-742-0059
Practice Address - Fax:478-746-3086
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA026284207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00292938CMedicaid
D45470Medicare UPIN