MEDICARE: DR. DERRIS WAYNE RAY M.D.

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	14423	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780679746
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DERRIS WAYNE RAY M.D.

Provider Business Mailing Address
First Line	:	309 WALNUT ST
Second Line	:	STE D
City	:	AMITE
State	:	LA
Zip	:	70422-2055
Country	:	US
Telephone Number	:	985-748-5158
Fax Number	:	985-748-9942

Provider Business Practice Location Address
First Line	:	309 WALNUT ST
Second Line	:	STE D
City	:	AMITE
State	:	LA
Zip	:	70422-2055
Country	:	US
Telephone Number	:	985-748-5158
Fax Number	:	985-748-9942

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2005
Last Update Date	:	07/24/2019

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