Healthcare Provider Details

I. General information

NPI: 1275521601
Provider Name (Legal Business Name): SCOTT KEVIN GRAY D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 11/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8604 DOLLARWAY RD
WHITE HALL AR
71602-2814
US

IV. Provider business mailing address

8604 DOLLARWAY RD
WHITE HALL AR
71602-2814
US

V. Phone/Fax

Practice location:
  • Phone: 870-536-3669
  • Fax: 870-536-0149
Mailing address:
  • Phone: 870-536-3669
  • Fax: 870-536-0149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number197
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number1597
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number218
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: