Provider Demographics
NPI:1740295161
Name:BRAY, KENNETH LEON (MD)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:LEON
Last Name:BRAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 ERIE CT STE 6040
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2510
Mailing Address - Country:US
Mailing Address - Phone:708-386-1301
Mailing Address - Fax:708-386-3053
Practice Address - Street 1:1 ERIE CT STE 6040
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2510
Practice Address - Country:US
Practice Address - Phone:708-386-1301
Practice Address - Fax:708-386-3053
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036085284207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036085284Medicaid
IL036085284Medicaid