MEDICARE: DERRIS W RAY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1346871746
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DERRIS W RAY

Provider Business Mailing Address
First Line	:	309 WALNUT ST STE D
Second Line	:
City	:	AMITE
State	:	LA
Zip	:	70422-2039
Country	:	US
Telephone Number	:	985-748-5158
Fax Number	:	985-748-9942

Provider Business Practice Location Address
First Line	:	309 WALNUT ST STE D
Second Line	:
City	:	AMITE
State	:	LA
Zip	:	70422-2039
Country	:	US
Telephone Number	:	985-748-5158
Fax Number	:	985-748-9942

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	KIRSTEN T RAY
Credential	:
Telephone Number	:	985-748-5158

Provider Enumeration Date	:	02/04/2020
Last Update Date	:	02/04/2020

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Directions to “DERRIS W RAY ” Practice Location

Language	Start Address	Practice Location

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