Provider Demographics
NPI:1336159300
Name:GRAY, DESHAWNDRANIQUE D (MD)
Entity Type:Individual
Prefix:
First Name:DESHAWNDRANIQUE
Middle Name:D
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 1:120 N MILLER RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-9106
Mailing Address - Country:US
Mailing Address - Phone:817-473-7172
Mailing Address - Fax:817-473-7574
Practice Address - Street 1:120 N MILLER RD STE 100
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-9106
Practice Address - Country:US
Practice Address - Phone:817-473-7172
Practice Address - Fax:817-473-7574
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1721207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXM1721OtherTEXAS STATE LICENSE
TX179211101Medicaid
TX8U1640OtherBCBS PROVIDER NUMBER
TX8U1640OtherBCBS PROVIDER NUMBER
TX8L6732Medicare PIN