Provider Demographics
NPI:1740269588
Name:GRAY, DIRK M (OD)
Entity type:Individual
Prefix:
First Name:DIRK
Middle Name:M
Last Name:GRAY
Suffix:
Gender:M
Credentials:OD
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 1808
Mailing Address - Street 2:
Mailing Address - City:MC COOK
Mailing Address - State:NE
Mailing Address - Zip Code:69001-1808
Mailing Address - Country:US
Mailing Address - Phone:308-345-5800
Mailing Address - Fax:
Practice Address - Street 1:218 WEST D STREET
Practice Address - Street 2:
Practice Address - City:MC COOK
Practice Address - State:NE
Practice Address - Zip Code:69001-3739
Practice Address - Country:US
Practice Address - Phone:308-345-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1088152W00000X
KS1529152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE268004Medicare PIN
NEU63894Medicare UPIN
NE410031265Medicare PIN
KS650980Medicare PIN