Provider Demographics
NPI:1720090749
Name:KEITH A GRAY MD PA
Entity Type:Organization
Organization Name:KEITH A GRAY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:WISTERIA
Authorized Official - Middle Name:Y
Authorized Official - Last Name:WYCHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-839-5063
Mailing Address - Street 1:PO BOX 568987
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32856-8987
Mailing Address - Country:US
Mailing Address - Phone:407-423-9920
Mailing Address - Fax:407-423-0545
Practice Address - Street 1:100 W GORE ST
Practice Address - Street 2:SUITE 303
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1044
Practice Address - Country:US
Practice Address - Phone:407-423-9920
Practice Address - Fax:407-423-0545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME41485207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255117900Medicaid
FL47582OtherBC/BS
FL255117900Medicaid
FLK0404Medicare ID - Type UnspecifiedPRACTICE GROUP NUMBER