Provider Demographics
NPI:1336422252
Name:GRAY, KATHLEEN (M,D)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:M,D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3930 4TH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-3119
Mailing Address - Country:US
Mailing Address - Phone:858-382-8106
Mailing Address - Fax:619-297-2244
Practice Address - Street 1:3930 4TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3119
Practice Address - Country:US
Practice Address - Phone:858-382-8106
Practice Address - Fax:619-297-2244
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-27
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG661522083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine