Provider Demographics
NPI:1669656351
Name:GRAY, MARK E (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:E
Last Name:GRAY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:595 PARK AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95110-2641
Mailing Address - Country:US
Mailing Address - Phone:408-410-3497
Mailing Address - Fax:408-947-8460
Practice Address - Street 1:595 PARK AVE STE 101
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95110-2641
Practice Address - Country:US
Practice Address - Phone:408-410-3497
Practice Address - Fax:408-947-8460
Is Sole Proprietor?:No
Enumeration Date:2007-12-18
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18229111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ40577ZOtherBLUE SHIELD
CADC0182290Medicare PIN