Provider Demographics
NPI:1437169521
Name:GRAYSON, WAYNE E (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:E
Last Name:GRAYSON
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-795-0659
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:906 SIXTH AVE
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-3802
Practice Address - Country:US
Practice Address - Phone:601-798-7529
Practice Address - Fax:601-798-7553
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06726207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS640507572XPOtherAMERICAN ADMIN GROUP
MS04208026Medicaid
LA1589578Medicaid
MS04208026Medicaid
LA1589578Medicaid
MS080003961Medicare PIN