Provider Demographics
NPI:1619924610
Name:GRAY, JAMIE E (MD)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:E
Last Name:GRAY
Suffix:
Gender:F
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 1749
Mailing Address - Street 2:C/O DEB NOVAK CREDENTIALING
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-1749
Mailing Address - Country:US
Mailing Address - Phone:970-926-6340
Mailing Address - Fax:970-926-6348
Practice Address - Street 1:181 W MEADOW DR
Practice Address - Street 2:SUITE 800 C/O DEB NOVAK CREDENTIALING
Practice Address - City:VAIL
Practice Address - State:CO
Practice Address - Zip Code:81657-5242
Practice Address - Country:US
Practice Address - Phone:970-476-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA20008329207R00000X
CO44791207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO88877027Medicaid
CO88877027Medicaid
COI59059Medicare UPIN