Provider Demographics
NPI:1902824162
Name:BRAY, SHELLY C (MD)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:C
Last Name:BRAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:CONLY
Other - Last Name:PERRIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:303 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:ARKADELPHIA
Mailing Address - State:AR
Mailing Address - Zip Code:71923-5317
Mailing Address - Country:US
Mailing Address - Phone:870-464-1515
Mailing Address - Fax:870-464-1514
Practice Address - Street 1:303 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:ARKADELPHIA
Practice Address - State:AR
Practice Address - Zip Code:71923-5317
Practice Address - Country:US
Practice Address - Phone:870-464-1515
Practice Address - Fax:870-464-1514
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-4195207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR155215001Medicaid
AR06080018100OtherQUALCHOICE
AR762691OtherHEALTHLINK
AR7373851OtherAETNA
AR5N038Medicare PIN
ARP00381882Medicare PIN
AR7373851OtherAETNA
AR0904380014Medicare NSC