Provider Demographics
NPI:1275603672
Name:GRAY, GARY G (OD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:G
Last Name:GRAY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2490 N WATER ST
Mailing Address - Street 2:SUITE 16
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4251
Mailing Address - Country:US
Mailing Address - Phone:217-875-4646
Mailing Address - Fax:217-875-2870
Practice Address - Street 1:2490 N WATER ST
Practice Address - Street 2:SUITE 16
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4251
Practice Address - Country:US
Practice Address - Phone:217-875-4646
Practice Address - Fax:217-875-2870
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152WC0802X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4056086OtherBCBCS
IL5884008OtherBCBS
IL6259GOtherUNITED HEALTHCARE
IL0159620001OtherDMERC ADMINISTAR
TN4056086OtherBCBCS
IL671900Medicare PIN