Provider Demographics
NPI:1356322077
Name:GRAY, JON HARVEY (MD)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:HARVEY
Last Name:GRAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JON
Other - Middle Name:HARVEY
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:6034 ST. CHARLES AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70118
Mailing Address - Country:US
Mailing Address - Phone:504-296-7959
Mailing Address - Fax:
Practice Address - Street 1:1701 OAK PARK BLVD.
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601
Practice Address - Country:US
Practice Address - Phone:337-494-3036
Practice Address - Fax:337-494-2181
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022139207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1668974Medicaid
LA66897Medicaid
LA66897Medicaid
LAG14546Medicare UPIN