Provider Demographics
NPI:1679735336
Name:RAY, THOMAS BRENT (DPM)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:BRENT
Last Name:RAY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 W ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-5337
Mailing Address - Country:US
Mailing Address - Phone:912-283-6471
Mailing Address - Fax:912-283-6471
Practice Address - Street 1:501 W ONEIDA ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-5337
Practice Address - Country:US
Practice Address - Phone:912-283-6471
Practice Address - Fax:912-283-6471
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPODPOD001158213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00949916OtherRAILROAD MEDICARE
GA003108317AMedicaid
202I487450Medicare PIN