Provider Demographics
NPI:1326073321
Name:DEGRAY, STEPHEN ALAN (MD)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:ALAN
Last Name:DEGRAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:WESTWOOD MEDICAL PARK
Mailing Address - Street 2:UNIT 7
Mailing Address - City:BLUEFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:24605
Mailing Address - Country:US
Mailing Address - Phone:276-322-5641
Mailing Address - Fax:276-322-5189
Practice Address - Street 1:WESTWOOD MEDICAL PARK
Practice Address - Street 2:UNIT 7
Practice Address - City:BLUEFIELD
Practice Address - State:VA
Practice Address - Zip Code:24605
Practice Address - Country:US
Practice Address - Phone:276-322-5641
Practice Address - Fax:276-322-5189
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101039286207Q00000X
WV10867207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0055063000Medicaid
VA5603781Medicaid
VA005603781Medicaid
VA005603781Medicaid
GA010066049Medicare PIN
WV0055063000Medicaid
VA5603781Medicaid