Provider Demographics
NPI:1720247364
Name:GRAY, FABIENNE LEE (MD)
Entity Type:Individual
Prefix:
First Name:FABIENNE
Middle Name:LEE
Last Name:GRAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1542 TULANE AVE RM 741
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-2865
Mailing Address - Country:US
Mailing Address - Phone:504-568-4750
Mailing Address - Fax:504-568-4730
Practice Address - Street 1:200 HENRY CLAY AVE
Practice Address - Street 2:OFFICE OF PEDIATRIC SURGERY
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118
Practice Address - Country:US
Practice Address - Phone:504-896-3997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.2057212086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1091588Medicaid