Healthcare Provider Details

I. General information

NPI: 1427341015
Provider Name (Legal Business Name): RUSSELL AUSTIN GRAY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2011
Last Update Date: 09/08/2022
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BODIN CIR
FAIRFIELD CA
94535-1809
US

IV. Provider business mailing address

101 BODIN CIR
FAIRFIELD CA
94535-1809
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-3000
  • Fax:
Mailing address:
  • Phone: 707-423-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number46904
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License Number46904
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: