Provider Demographics
NPI:1457320210
Name:GRAY, DAVID R (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:R
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:PO BOX 4699
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-4699
Mailing Address - Country:US
Mailing Address - Phone:765-449-2732
Mailing Address - Fax:765-449-1196
Practice Address - Street 1:1250 S CREASY LN
Practice Address - Street 2:SUITE A
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4960
Practice Address - Country:US
Practice Address - Phone:765-449-2732
Practice Address - Fax:765-449-1196
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01041342A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000110554OtherANTHEM PROVIDER
IN200165100Medicaid
IN000000110554OtherANTHEM PROVIDER
IND39145Medicare UPIN
IN815140FMedicare PIN