Healthcare Provider Details

I. General information

NPI: 1962515684
Provider Name (Legal Business Name): TODD GRAY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

268 BROOKLEY AVE
BOLLING AFB DC
20032
US

IV. Provider business mailing address

1305 RIVER BIRCH PL
ACCOKEEK MD
20607-3294
US

V. Phone/Fax

Practice location:
  • Phone: 202-404-3603
  • Fax: 202-404-1256
Mailing address:
  • Phone: 301-283-5475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: