Provider Demographics
NPI:1790909067
Name:GRAY, LAURA ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:ANN
Last Name:GRAY
Suffix:
Gender:F
Credentials:MD
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 3900
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803-3900
Mailing Address - Country:US
Mailing Address - Phone:662-842-9677
Mailing Address - Fax:662-842-0309
Practice Address - Street 1:905 GARFIELD ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-5737
Practice Address - Country:US
Practice Address - Phone:662-842-9677
Practice Address - Fax:662-842-0309
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS155602081S0010X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0119451Medicaid
MSF09216Medicare UPIN
MS250000034Medicare ID - Type Unspecified