Provider Demographics
NPI:1285813436
Name:JOHN P GRAY MD PA
Entity Type:Organization
Organization Name:JOHN P GRAY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-675-1065
Mailing Address - Street 1:4100 INTERNATIONAL PLAZA
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4823
Mailing Address - Country:US
Mailing Address - Phone:817-334-0530
Mailing Address - Fax:817-877-0350
Practice Address - Street 1:1204 N MOUND ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4027
Practice Address - Country:US
Practice Address - Phone:936-462-7844
Practice Address - Fax:936-462-7855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7025207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX180299301Medicaid
TX0046NAOtherBC/BS
TX0046NAOtherBCBS
TX180299301Medicaid
DE3605Medicare PIN
TX0046NAOtherBC/BS