Healthcare Provider Details

I. General information

NPI: 1023072105
Provider Name (Legal Business Name): GEORGE THOMPSON GRAY III D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 BRADEN ST EMERGENCY DEPT
JACKSONVILLE AR
72076-3721
US

IV. Provider business mailing address

PO BOX 3925
SHREVEPORT LA
71133-3925
US

V. Phone/Fax

Practice location:
  • Phone: 501-985-7000
  • Fax:
Mailing address:
  • Phone: 800-684-0052
  • Fax: 405-844-1794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberR-3735
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR3735
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: