Provider Demographics
NPI:1497765218
Name:GRAY, JANET
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 S ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2353
Mailing Address - Country:US
Mailing Address - Phone:812-339-1691
Mailing Address - Fax:812-337-2438
Practice Address - Street 1:831 DILLON DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-8048
Practice Address - Country:US
Practice Address - Phone:765-983-8000
Practice Address - Fax:765-983-8609
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28068440A2084P0800X
IN70000045A2084P0800X
IN70000045B2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN231190NNMedicare ID - Type UnspecifiedGRAYMEDICARERURAL
IN954050TTMedicare ID - Type UnspecifiedGRAYMENICAREURBAN