Provider Demographics
NPI:1528412533
Name:ROBERGE, GRAY
Entity Type:Individual
Prefix:
First Name:GRAY
Middle Name:
Last Name:ROBERGE
Suffix:
Gender:M
Credentials:
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 2666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-0001
Mailing Address - Country:US
Mailing Address - Phone:505-923-5360
Mailing Address - Fax:
Practice Address - Street 1:201 CEDAR ST SE STE 5660
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4920
Practice Address - Country:US
Practice Address - Phone:505-563-6565
Practice Address - Fax:505-563-6564
Is Sole Proprietor?:No
Enumeration Date:2016-04-15
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6177-851208800000X
NMMD2020-1074208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology