Provider Demographics
NPI:1356645469
Name:GRAY, BETHANY (DO)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 TECHNOLOGY DR
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-2302
Mailing Address - Country:US
Mailing Address - Phone:949-923-3277
Mailing Address - Fax:855-812-5865
Practice Address - Street 1:10601 WALKER ST
Practice Address - Street 2:SUITE 250
Practice Address - City:CYPRESS
Practice Address - State:CA
Practice Address - Zip Code:90630-4733
Practice Address - Country:US
Practice Address - Phone:714-252-8311
Practice Address - Fax:714-252-8339
Is Sole Proprietor?:No
Enumeration Date:2011-01-04
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11893207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB225578Medicare PIN