Provider Demographics
NPI:1346466299
Name:GRAY, ENOCH KAZEEM (MD)
Entity Type:Individual
Prefix:DR
First Name:ENOCH
Middle Name:KAZEEM
Last Name:GRAY
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 1:7074 GLENGARRY DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-3020
Mailing Address - Country:US
Mailing Address - Phone:614-359-4710
Mailing Address - Fax:
Practice Address - Street 1:6439 GARNERS FERRY RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-1638
Practice Address - Country:US
Practice Address - Phone:803-776-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.089004207R00000X
IL036.122290207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3121197Medicaid
OH4315241Medicare PIN