Provider Demographics
NPI:1831514025
Name:GRAY, BRYAN (DO)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:GRAY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 BELLEFONTAINE AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-2881
Mailing Address - Country:US
Mailing Address - Phone:419-998-8297
Mailing Address - Fax:419-226-8309
Practice Address - Street 1:525 N EASTOWN RD STE A
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45807-2268
Practice Address - Country:US
Practice Address - Phone:419-998-8297
Practice Address - Fax:419-226-8309
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-24
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101021720207N00000X, 207N00000X
OH34.013501207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH34.013501OtherOH LICENSE
MI5101021720OtherMI LICENSE