Provider Demographics
NPI:1720067119
Name:RAY, GERALD L (DO)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:L
Last Name:RAY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-1709
Mailing Address - Country:US
Mailing Address - Phone:817-473-6750
Mailing Address - Fax:817-477-1708
Practice Address - Street 1:501 E BROAD ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-1709
Practice Address - Country:US
Practice Address - Phone:817-473-6750
Practice Address - Fax:817-477-1708
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6260207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145286404Medicaid
TX8F4535OtherBCBS
TX930122549OtherMEDICARE RAILROAD
TX145286406Medicaid
TX145286403Medicaid
TX145286405Medicaid
TX8A0108Medicare PIN
TX145286404Medicaid
TXG76529Medicare UPIN
TX8F4535OtherBCBS
TX8L9288Medicare PIN