Provider Demographics
NPI:1750397675
Name:GRAY, J. BRIAN (OD)
Entity type:Individual
Prefix:DR
First Name:J.
Middle Name:BRIAN
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 1:114 E OAK AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-3561
Mailing Address - Country:US
Mailing Address - Phone:870-935-5454
Mailing Address - Fax:870-935-2643
Practice Address - Street 1:114 E OAK AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3561
Practice Address - Country:US
Practice Address - Phone:870-935-5454
Practice Address - Fax:870-935-2643
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2414152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR48741OtherINDIVIDUAL BCBS
AR149197722Medicaid
AR42186OtherDAVIS VISION
AR431961530OtherVISION SERVICE PLAN (VSP)
AR431961530OtherVBA
AR123724722Medicaid
AR431961530OtherVCA
AR12189OtherSPECTERA
AR207398OtherEYEMED
AR4596720001OtherPALMETTO GBA
ARU50674Medicare UPIN
AR48741B379Medicare PIN