Provider Demographics
NPI:1821006396
Name:GRAY, YEV (DPM)
Entity Type:Individual
Prefix:DR
First Name:YEV
Middle Name:
Last Name:GRAY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:YEVGENY
Other - Middle Name:
Other - Last Name:MANDELBROYT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:10 S RIVERSIDE PLZ
Mailing Address - Street 2:STE 19 EAST
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-3728
Mailing Address - Country:US
Mailing Address - Phone:773-770-0140
Mailing Address - Fax:312-277-6757
Practice Address - Street 1:10 S RIVERSIDE PLZ
Practice Address - Street 2:STE 19 EAST
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606-3728
Practice Address - Country:US
Practice Address - Phone:773-770-0140
Practice Address - Fax:312-277-6757
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-004841213E00000X
WI751-025213E00000X
OH36-003405213E00000X
MO2002002944213E00000X
IN07000848A213E00000X
MN685213E00000X
MI5901002069213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU66729Medicare UPIN
WI000001214Medicare PIN
WI000046228Medicare PIN
IL214837Medicare PIN
WI000057050Medicare PIN
WI000060187Medicare PIN
WI000015065Medicare PIN
IL208958Medicare PIN
WI000019060Medicare PIN
IL212248Medicare PIN
WI000012085Medicare PIN
WI000013275Medicare PIN
WI000054422Medicare PIN
IL208957Medicare PIN
WI000036020Medicare PIN
WI000040200Medicare PIN
IL214673Medicare PIN