Provider Demographics
NPI:1639296957
Name:GRAY, JILLIAN S (DO)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:S
Last Name:GRAY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:S
Other - Last Name:THACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:18685 MAIN ST STE 101-622
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-1723
Mailing Address - Country:US
Mailing Address - Phone:714-941-2259
Mailing Address - Fax:714-941-2259
Practice Address - Street 1:17122 BEACH BLVD STE 203
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647
Practice Address - Country:US
Practice Address - Phone:714-941-2259
Practice Address - Fax:714-455-1380
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8683207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX86830Medicaid
CAW20A8683BMedicare PIN
CAI48574Medicare UPIN