Provider Demographics
NPI:1861481517
Name:GRAY, KRISTEN DAVID (MD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:DAVID
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 1:290 CLYDE MORRIS BLVD STE C2
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-8204
Mailing Address - Country:US
Mailing Address - Phone:386-259-6026
Mailing Address - Fax:
Practice Address - Street 1:290 CLYDE MORRIS BLVD STE C2
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8204
Practice Address - Country:US
Practice Address - Phone:386-259-6026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85090207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL593339550OtherTAX IDENTIFICATION NUMBER
FL592696120OtherTAX IDENIFICATION
FL264274300Medicaid
FLK9529OtherMEDICARE GROUP NUMBER
FL593339550OtherWINTER PARK FAMILY HEALTH CENTER, INC
FL1114901816OtherWINTER PARK FAMILY HEALTH CENTER, INC NPI
FL40471OtherMEDICARE GROUP
FLK9529OtherMEDICARE GROUP NUMBER
C43076Medicare UPIN
FLK9529OtherMEDICARE GROUP NUMBER
FLDD844YMedicare PIN