Healthcare Provider Details

I. General information

NPI: 1356645469
Provider Name (Legal Business Name): BETHANY GRAY D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2011
Last Update Date: 09/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10601 WALKER ST SUITE 250
CYPRESS CA
90630-4733
US

IV. Provider business mailing address

11 TECHNOLOGY DR
IRVINE CA
92618-2302
US

V. Phone/Fax

Practice location:
  • Phone: 714-252-8311
  • Fax: 714-252-8339
Mailing address:
  • Phone: 949-923-3277
  • Fax: 855-812-5865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A11893
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: