Provider Demographics
NPI:1649239468
Name:GRAY, ROBERT G (PT)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:G
Last Name:GRAY
Suffix:
Gender:M
Credentials:PT
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 80700
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79708-0700
Mailing Address - Country:US
Mailing Address - Phone:432-570-7850
Mailing Address - Fax:432-520-2528
Practice Address - Street 1:4304 ANDREWS HWY
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79703-4824
Practice Address - Country:US
Practice Address - Phone:432-570-7850
Practice Address - Fax:432-520-2528
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1047538225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX611094Medicare ID - Type Unspecified
TX8F21058Medicare UPIN