Provider Demographics
NPI:1497792030
Name:GRAY, ROBERT K (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:K
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 48904
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-0904
Mailing Address - Country:US
Mailing Address - Phone:323-297-0670
Mailing Address - Fax:
Practice Address - Street 1:2202 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5706
Practice Address - Country:US
Practice Address - Phone:310-264-9000
Practice Address - Fax:310-264-9004
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG123882085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G123880OtherBLUE SHIELD OF CA
CA00G123880Medicaid
A38649Medicare UPIN
CA00G123880OtherBLUE SHIELD OF CA