Provider Demographics
NPI:1336136829
Name:RAY, MARK JAMES (DPM)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JAMES
Last Name:RAY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5944 ROUTE 981
Mailing Address - Street 2:
Mailing Address - City:LATROBE
Mailing Address - State:PA
Mailing Address - Zip Code:15650-2685
Mailing Address - Country:US
Mailing Address - Phone:724-537-9008
Mailing Address - Fax:724-537-9088
Practice Address - Street 1:5944 ROUTE 981
Practice Address - Street 2:
Practice Address - City:LATROBE
Practice Address - State:PA
Practice Address - Zip Code:15650-2685
Practice Address - Country:US
Practice Address - Phone:724-537-9008
Practice Address - Fax:724-537-9088
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC004546L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA017730000003Medicaid
PAU78184Medicare UPIN
PA033086Medicare ID - Type Unspecified