Provider Demographics
NPI:1679587422
Name:GRAY, TODD A (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:A
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 997
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58502-0997
Mailing Address - Country:US
Mailing Address - Phone:701-530-6500
Mailing Address - Fax:
Practice Address - Street 1:900 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4520
Practice Address - Country:US
Practice Address - Phone:701-530-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-32887208800000X
ND12115208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1454325Medicaid
E22755Medicare UPIN
NDN719629Medicare PIN
KS106971OtherBCBS OF KANSAS
NDN719629Medicare PIN
KS200536990AMedicaid
ND16517Medicaid
NM15123Medicaid