Provider Demographics
NPI:1891875167
Name:GRAY-CLARKE, VIRGINIA L (MD)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:L
Last Name:GRAY-CLARKE
Suffix:
Gender:F
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:P.O. BOX 789
Mailing Address - Street 2:50 HOSPITAL HILL ROAD
Mailing Address - City:SHARON
Mailing Address - State:CT
Mailing Address - Zip Code:06069
Mailing Address - Country:US
Mailing Address - Phone:860-364-4471
Mailing Address - Fax:
Practice Address - Street 1:29 HOSPITAL HILL RD
Practice Address - Street 2:SUITE 1600
Practice Address - City:SHARON
Practice Address - State:CT
Practice Address - Zip Code:06069-2095
Practice Address - Country:US
Practice Address - Phone:860-364-5585
Practice Address - Fax:860-364-5078
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT038023208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001380237Medicaid
CT010038023OtherBLUE CROSS BLUE SHIELD
NY565211OtherBLUE CROSS BLUE SHIELD
NY565211OtherBLUE CROSS BLUE SHIELD