Provider Demographics
NPI:1376599340
Name:GRAY, JHANELLE (MD)
Entity Type:Individual
Prefix:
First Name:JHANELLE
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12902 USF MAGNOLIA DR
Mailing Address - Street 2:FOB 1 - THOR
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-9416
Mailing Address - Country:US
Mailing Address - Phone:813-745-3050
Mailing Address - Fax:813-745-3027
Practice Address - Street 1:12902 USF MAGNOLIA DR
Practice Address - Street 2:FOB 1 - THOR
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9416
Practice Address - Country:US
Practice Address - Phone:813-745-3050
Practice Address - Fax:813-745-3027
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91405207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL275362600Medicaid
FL53062OtherBCBS
FLI70261Medicare UPIN
FL275362600Medicaid