Provider Demographics
NPI:1831124056
Name:GRAY, BRIAN J (DC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:GRAY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12277 DE PAUL DR
Mailing Address - Street 2:SUITE 305
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2516
Mailing Address - Country:US
Mailing Address - Phone:314-291-3399
Mailing Address - Fax:314-291-5420
Practice Address - Street 1:12277 DE PAUL DR
Practice Address - Street 2:SUITE 305
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2516
Practice Address - Country:US
Practice Address - Phone:314-291-3399
Practice Address - Fax:314-291-5420
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO006158111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO35542OtherBLUE CROSS BLUE SHIELD
MO35542OtherBLUE CROSS BLUE SHIELD