Provider Demographics
NPI:1881600732
Name:GRAY, JERRY L (MD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:L
Last Name:GRAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1266
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-1266
Mailing Address - Country:US
Mailing Address - Phone:808-261-3326
Mailing Address - Fax:808-263-4604
Practice Address - Street 1:1190 WAIANUENUE AVE
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-2020
Practice Address - Country:US
Practice Address - Phone:808-261-3326
Practice Address - Fax:808-263-4604
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG4461207P00000X
HIMD-12017207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI535932Medicaid
TX8A9550OtherBLUECROSS BLUESHIELD
HI0000240366OtherHMSA
B87960Medicare UPIN
HIH55378Medicare ID - Type Unspecified
TX8A9550OtherBLUECROSS BLUESHIELD