Provider Demographics
NPI:1740267673
Name:GRAY, GARY D (DO)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:D
Last Name:GRAY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:855 A AVE NE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-5057
Mailing Address - Country:US
Mailing Address - Phone:319-368-9300
Mailing Address - Fax:319-368-5690
Practice Address - Street 1:855 A AVE NE
Practice Address - Street 2:SUITE 30
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-5057
Practice Address - Country:US
Practice Address - Phone:319-368-9300
Practice Address - Fax:319-368-5690
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2012-05-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IA01454208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0128314Medicaid
IA370022580OtherRR MEDICARE
IA1740267673Medicaid
IA370022580OtherRR MEDICARE
IAA14411Medicare UPIN
IA719260120Medicare PIN