Provider Demographics
NPI:1669622080
Name:GRAY, JENNIFER MARIE (DO)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MARIE
Last Name:GRAY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:200 BELLE TERRE RD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1928
Mailing Address - Country:US
Mailing Address - Phone:631-474-6012
Mailing Address - Fax:631-474-6448
Practice Address - Street 1:200 BELLE TERRE RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1928
Practice Address - Country:US
Practice Address - Phone:631-474-6012
Practice Address - Fax:631-474-6448
Is Sole Proprietor?:No
Enumeration Date:2008-09-22
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY2567602081N0008X, 204R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081N0008XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationNeuromuscular Medicine
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic Medicine