Provider Demographics
NPI:1710005509
Name:SCOTT K GRAY, DPM
Entity Type:Organization
Organization Name:SCOTT K GRAY, DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:K
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:870-536-3669
Mailing Address - Street 1:1724 W 42ND AVE
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-7008
Mailing Address - Country:US
Mailing Address - Phone:870-536-3669
Mailing Address - Fax:870-536-0149
Practice Address - Street 1:1724 W 42ND AVE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-7008
Practice Address - Country:US
Practice Address - Phone:870-536-3669
Practice Address - Fax:870-536-0149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR197213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARU89815Medicare UPIN
TX00811PMedicare ID - Type Unspecified
AR5W846Medicare ID - Type Unspecified
AR4666670001Medicare NSC