Provider Demographics
NPI:1518980051
Name:GRAY, PHILLIP ADAM (O D)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:ADAM
Last Name:GRAY
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 S FULTON ST
Mailing Address - Street 2:
Mailing Address - City:IUKA
Mailing Address - State:MS
Mailing Address - Zip Code:38852-2328
Mailing Address - Country:US
Mailing Address - Phone:662-423-3785
Mailing Address - Fax:662-423-2849
Practice Address - Street 1:105 S FULTON ST
Practice Address - Street 2:
Practice Address - City:IUKA
Practice Address - State:MS
Practice Address - Zip Code:38852-2328
Practice Address - Country:US
Practice Address - Phone:662-423-3785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS756152W00000X
TN2679152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06673726Medicaid
MS06673726Medicaid
MSP00350644Medicare PIN
MS410000377Medicare PIN