Provider Demographics
NPI:1295768034
Name:GRAY, FAITH MICHELLE (MD)
Entity type:Individual
Prefix:MISS
First Name:FAITH
Middle Name:MICHELLE
Last Name:GRAY
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:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30048-0308
Mailing Address - Country:US
Mailing Address - Phone:770-806-8710
Mailing Address - Fax:770-806-0564
Practice Address - Street 1:3993 LAWRENCEVILLE HWY NW
Practice Address - Street 2:SUITE 115
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-2897
Practice Address - Country:US
Practice Address - Phone:770-806-8710
Practice Address - Fax:770-806-0564
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036165207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000675135FMedicaid
GA000675135FMedicaid
GA11BDRVMMedicare ID - Type Unspecified