Healthcare Provider Details

I. General information

NPI: 1184618480
Provider Name (Legal Business Name): RICHARD JEFFREY GRAYSON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2005
Last Update Date: 06/27/2021
Certification Date: 06/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 AVON MEADOW LN
AVON CT
06001-3753
US

IV. Provider business mailing address

40 AVON MEADOW LN
AVON CT
06001-3753
US

V. Phone/Fax

Practice location:
  • Phone: 860-677-7733
  • Fax: 860-677-7512
Mailing address:
  • Phone: 860-677-7733
  • Fax: 860-677-7512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number1437
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberP313
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberP313
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: