Provider Demographics
NPI:1912299157
Name:RAY, ADAM CLINTON (IDC)
Entity Type:Individual
Prefix:MR
First Name:ADAM
Middle Name:CLINTON
Last Name:RAY
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 LEDGEWOOD RD
Mailing Address - Street 2:APT 405
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-6611
Mailing Address - Country:US
Mailing Address - Phone:903-517-6146
Mailing Address - Fax:
Practice Address - Street 1:163 LEDGEWOOD RD
Practice Address - Street 2:APT 405
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-6611
Practice Address - Country:US
Practice Address - Phone:903-517-6146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-06
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman