Provider Demographics
NPI:1528029501
Name:RAY, BRIAN DAVID (DO)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:DAVID
Last Name:RAY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:400 S. BLAIRSFERRY CROSSING
Mailing Address - Street 2:SUITE A
Mailing Address - City:HIAWATHA
Mailing Address - State:IA
Mailing Address - Zip Code:52233-7988
Mailing Address - Country:US
Mailing Address - Phone:319-393-0783
Mailing Address - Fax:319-393-0427
Practice Address - Street 1:400 S. BLAIRSFERRY CROSSING
Practice Address - Street 2:SUITE A
Practice Address - City:HIAWATHA
Practice Address - State:IA
Practice Address - Zip Code:52233-7988
Practice Address - Country:US
Practice Address - Phone:319-393-0783
Practice Address - Fax:319-393-0427
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IAR7651207Q00000X
IA3734207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAP00708643OtherRR MEDICARE
IA1528029501Medicaid
IAI18311Medicare PIN
IA71926017Medicare PIN
IA1528029501Medicaid