Provider Demographics
NPI:1861451346
Name:GRAY, CAPTAIN K (MD)
Entity Type:Individual
Prefix:DR
First Name:CAPTAIN
Middle Name:K
Last Name:GRAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 BUTTERFIELD RD
Mailing Address - Street 2:STE 300
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1069
Mailing Address - Country:US
Mailing Address - Phone:630-725-2700
Mailing Address - Fax:
Practice Address - Street 1:10777 NALL AVE
Practice Address - Street 2:#315
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66211-1362
Practice Address - Country:US
Practice Address - Phone:913-345-2622
Practice Address - Fax:913-345-2699
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0416656202K00000X, 207R00000X
MO117885207R00000X
TXQ2669207R00000X
TNMD0000054563202K00000X
CT56083202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No202K00000XAllopathic & Osteopathic PhysiciansPhlebology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS17344014OtherBLUE CROSS BLUE SHIELD OF KANSAS CITY
MO17344024OtherBLUE CROSS BLUE SHIELD OF KANSAS CITY
KS110132045OtherMEDICARE RAILROAD
TX340731Medicare PIN
TX292521Medicare PIN
KS17344014OtherBLUE CROSS BLUE SHIELD OF KANSAS CITY
KSP00977828Medicare UPIN
TX470423YY2GMedicare PIN
MO17344024OtherBLUE CROSS BLUE SHIELD OF KANSAS CITY
TX340739Medicare PIN
TX470423YY2HMedicare PIN
KSB060000Medicare PIN
KSB062496Medicare PIN
TXTXB155426Medicare PIN
TX470423YMZSMedicare PIN
KSDR9090Medicare PIN
KS110132045OtherMEDICARE RAILROAD
TX470423YSWXMedicare PIN