Provider Demographics
NPI:1427407824
Name:GRAY, KATHERINE (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
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 1:120 DESERT SAGE WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-1038
Mailing Address - Country:US
Mailing Address - Phone:208-587-3988
Mailing Address - Fax:208-587-3324
Practice Address - Street 1:120 DESERT SAGE WAY
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-1038
Practice Address - Country:US
Practice Address - Phone:208-875-3988
Practice Address - Fax:208-587-3324
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COTL0006271207Q00000X
IDM-14835207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine