Provider Demographics
NPI:1336281054
Name:GRAY, WAYNE S (OD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:S
Last Name:GRAY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10113 S CENTRAL PARK AVE
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-3716
Mailing Address - Country:US
Mailing Address - Phone:708-423-7625
Mailing Address - Fax:
Practice Address - Street 1:1 RIVER OAKS DRIVE
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409
Practice Address - Country:US
Practice Address - Phone:708-418-4147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist