Provider Demographics
NPI:1568451680
Name:GRAY, GORDON MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:MATTHEW
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 17527
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-7527
Mailing Address - Country:US
Mailing Address - Phone:406-728-8420
Mailing Address - Fax:
Practice Address - Street 1:2825 STOCKYARD RD
Practice Address - Street 2:BLDG I-200
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1503
Practice Address - Country:US
Practice Address - Phone:406-728-8420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT7558207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805002900Medicaid
MT0104520Medicaid
ID805002900Medicaid