Provider Demographics
NPI:1255338984
Name:BRAY, GINA VICK (DO)
Entity type:Individual
Prefix:DR
First Name:GINA
Middle Name:VICK
Last Name:BRAY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1369
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-0014
Mailing Address - Country:US
Mailing Address - Phone:662-342-5353
Mailing Address - Fax:662-393-9753
Practice Address - Street 1:187 STATELINE RD E
Practice Address - Street 2:SUITE 10
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-1704
Practice Address - Country:US
Practice Address - Phone:662-342-5353
Practice Address - Fax:662-393-9753
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15380207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0118418Medicaid
MS0118418Medicaid
G52317Medicare UPIN