Provider Demographics
NPI:1629103775
Name:RAY, LANCE (MD)
Entity Type:Individual
Prefix:DR
First Name:LANCE
Middle Name:
Last Name:RAY
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 1:1607 PLANTATION ROAD
Mailing Address - Street 2:
Mailing Address - City:MOHAVE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86440
Mailing Address - Country:US
Mailing Address - Phone:928-346-4679
Mailing Address - Fax:928-346-4686
Practice Address - Street 1:1607 PLANTATION ROAD
Practice Address - Street 2:
Practice Address - City:MOHAVE VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86440
Practice Address - Country:US
Practice Address - Phone:928-346-4679
Practice Address - Fax:928-346-4686
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA12094208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1669540316OtherBC/BS
AZ306467Medicaid
AZ306467Medicaid