Provider Demographics
NPI:1891787651
Name:GRAY, DOUGLAS L (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:L
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11108 PARKVIEW CIRCLE DR
Practice Address - Street 2:SUITE 5100
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1730
Practice Address - Country:US
Practice Address - Phone:260-266-2800
Practice Address - Fax:260-266-2805
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044841A208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00664358OtherRAILROAD MEDICARE
IN060048219OtherRAILROAD MEDICARE
IN200178590Medicaid
IN000000595620OtherANTHEM
INP00664358OtherRAILROAD MEDICARE
IN259180AMedicare PIN
IN200178590Medicaid