Provider Demographics
NPI:1356766935
Name:GRAY, DASETA (MED)
Entity type:Individual
Prefix:
First Name:DASETA
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5256 ST NICHOLAS AVE
Mailing Address - Street 2:SUITE 4J
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10026-3418
Mailing Address - Country:US
Mailing Address - Phone:347-524-4178
Mailing Address - Fax:877-212-7359
Practice Address - Street 1:5256 SAINT NICHOLAS AVE
Practice Address - Street 2:SUITE 4J
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10026-3418
Practice Address - Country:US
Practice Address - Phone:347-524-4178
Practice Address - Fax:877-212-7359
Is Sole Proprietor?:No
Enumeration Date:2014-02-19
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist