Provider Demographics
NPI:1457316705
Name:GRAY, BRIAN C (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:C
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 1:101 LAGUNA RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-3601
Mailing Address - Country:US
Mailing Address - Phone:714-992-5350
Mailing Address - Fax:714-992-8156
Practice Address - Street 1:101 LAGUNA RD STE 100
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3601
Practice Address - Country:US
Practice Address - Phone:714-992-5350
Practice Address - Fax:714-992-8156
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54225207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA54225C7Medicare ID - Type Unspecified
A54225Medicare UPIN