Healthcare Provider Details

I. General information

NPI: 1609073022
Provider Name (Legal Business Name): DERRICK ANDRE GRAY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 10/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W. MAPLE SUITE 102
SPRINGDALE AR
72764-5370
US

IV. Provider business mailing address

601 W. MAPLE SUITE 102
SPRINGDALE AR
72764-5370
US

V. Phone/Fax

Practice location:
  • Phone: 479-750-6585
  • Fax: 479-757-2963
Mailing address:
  • Phone: 479-750-6585
  • Fax: 479-757-2963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE6424
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: