Provider Demographics
NPI:1780679746
Name:RAY, DERRIS WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:DERRIS
Middle Name:WAYNE
Last Name:RAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:309 WALNUT ST
Mailing Address - Street 2:STE D
Mailing Address - City:AMITE
Mailing Address - State:LA
Mailing Address - Zip Code:70422-2055
Mailing Address - Country:US
Mailing Address - Phone:985-748-5158
Mailing Address - Fax:985-748-9942
Practice Address - Street 1:309 WALNUT ST
Practice Address - Street 2:STE D
Practice Address - City:AMITE
Practice Address - State:LA
Practice Address - Zip Code:70422-2055
Practice Address - Country:US
Practice Address - Phone:985-748-5158
Practice Address - Fax:985-748-9942
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-15
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA14423208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1306533Medicaid
LA54886Medicare ID - Type Unspecified
LA1306533Medicaid