Provider Demographics
NPI:1407846090
Name:GRAY, RICHARD J (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
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 1:40 VALLEY STREAM PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-1407
Mailing Address - Country:US
Mailing Address - Phone:610-644-8900
Mailing Address - Fax:610-644-8909
Practice Address - Street 1:7959 BUSTLETON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-3320
Practice Address - Country:US
Practice Address - Phone:215-742-5662
Practice Address - Fax:215-742-5663
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD177042085R0202X, 2085R0204X
PAMD4341942085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA125141RS8OtherMEDICARE
OR102173425Medicaid
PAMD434194OtherMEDICAL LICENSE NUMBER
PA125141RS8OtherMEDICARE
OR102173425Medicaid