Provider Demographics
NPI:1285644039
Name:GRAY, JENNIFER P (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:P
Last Name:GRAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:455 BOSTON POST RD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-1516
Mailing Address - Country:US
Mailing Address - Phone:860-388-9799
Mailing Address - Fax:860-388-6646
Practice Address - Street 1:455 BOSTON POST RD
Practice Address - Street 2:SUITE 10
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-1516
Practice Address - Country:US
Practice Address - Phone:860-388-9799
Practice Address - Fax:860-388-6646
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RI11512207N00000X
CT044955207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTI29941Medicare UPIN