Provider Demographics
NPI:1518988328
Name:GRAY, JIM PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:PATRICK
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 1:1365 MARKET ST
Mailing Address - Street 2:C/O LUJEAN TRUMBLE
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39567-6604
Mailing Address - Country:US
Mailing Address - Phone:228-762-1353
Mailing Address - Fax:228-762-1359
Practice Address - Street 1:2809 DENNY AVE
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581-5301
Practice Address - Country:US
Practice Address - Phone:228-762-1353
Practice Address - Fax:228-762-1359
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS193762085R0202X
OH35-0959442085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS001689087Medicaid
MSI65108Medicare UPIN