Provider Demographics
NPI:1831200369
Name:GRAY, WILLIAM R (DO)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
Last Name:GRAY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:NORTHERN
Other - Middle Name:MICHIGAN
Other - Last Name:DERMATOLOGY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:125 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHEBOYGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49721-1637
Mailing Address - Country:US
Mailing Address - Phone:231-627-3800
Mailing Address - Fax:231-627-2482
Practice Address - Street 1:125 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CHEBOYGAN
Practice Address - State:MI
Practice Address - Zip Code:49721-1637
Practice Address - Country:US
Practice Address - Phone:231-627-3800
Practice Address - Fax:231-627-2482
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIWG008271207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3055165Medicaid
MI0751600054OtherBLUE CROSS BLUE SHIELD
MI5160005OtherBLUE CARE NETWORK
MIE30929Medicare UPIN
MI3055165Medicaid