Provider Demographics
NPI:1790825966
Name:GRAY, DEETTA (MD, FAAD, FRCPC)
Entity Type:Individual
Prefix:
First Name:DEETTA
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:MD, FAAD, FRCPC
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 3418
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98083-3418
Mailing Address - Country:US
Mailing Address - Phone:425-999-2628
Mailing Address - Fax:425-646-2965
Practice Address - Street 1:1515 116TH AVE NE
Practice Address - Street 2:STE 307
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3811
Practice Address - Country:US
Practice Address - Phone:425-999-2628
Practice Address - Fax:425-646-2965
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA025209 MD00035417207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology