Provider Demographics
NPI:1841254570
Name:GRAY, PHILLIP HAROLD (OD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:HAROLD
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 1:105 S FULTON ST
Mailing Address - Street 2:
Mailing Address - City:IUKA
Mailing Address - State:MS
Mailing Address - Zip Code:38852-2328
Mailing Address - Country:US
Mailing Address - Phone:662-423-3785
Mailing Address - Fax:662-423-2849
Practice Address - Street 1:105 S FULTON ST
Practice Address - Street 2:
Practice Address - City:IUKA
Practice Address - State:MS
Practice Address - Zip Code:38852-2328
Practice Address - Country:US
Practice Address - Phone:662-423-3785
Practice Address - Fax:662-423-2849
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-12
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS469152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00087882Medicaid
MS00087882Medicaid
MST20791Medicare UPIN
MS560945932Medicare PIN