Provider Demographics
NPI:1306846795
Name:RAY, MARY ELIZABETH (DO)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELIZABETH
Last Name:RAY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:SHORT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:316 PASEO REYES DR
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-8464
Mailing Address - Country:US
Mailing Address - Phone:904-342-0219
Mailing Address - Fax:904-460-2783
Practice Address - Street 1:316 PASEO REYES DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-8464
Practice Address - Country:US
Practice Address - Phone:904-342-0219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02005514A207Q00000X
DCDO034780207Q00000X
NC2018-02504207Q00000X
SC81617207Q00000X
VA0102205452207Q00000X
FLOS 10534207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00756545OtherMEDICARE RAILROAD
FL001090100Medicaid
FLP00756545OtherMEDICARE RAILROAD
FLBU037ZMedicare PIN
MIN56870001Medicare ID - Type Unspecified