Provider Demographics
NPI:1932128477
Name:GRAYSON, KEVIN DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:DAVID
Last Name:GRAYSON
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 1:612 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-1248
Mailing Address - Country:US
Mailing Address - Phone:541-663-3150
Mailing Address - Fax:541-975-5111
Practice Address - Street 1:612 SUNSET DR
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-1248
Practice Address - Country:US
Practice Address - Phone:541-663-3150
Practice Address - Fax:541-975-5111
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23354208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORH1258-02OtherOTHER
OR287182Medicaid
9305053253002OtherEMPLOYER ID
ORH1258-02OtherOTHER
ORI47450Medicare UPIN
OR133966Medicare ID - Type UnspecifiedPIN-ZGBDR