Healthcare Provider Details

I. General information

NPI: 1679782411
Provider Name (Legal Business Name): SCOTT K GRAY DPM PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
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 Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number197
License Number StateAR

VIII. Authorized Official

Name: DR. SCOTT K GRAY
Title or Position: PRESIDENT SECRETARY
Credential: DPM
Phone: 870-536-3669