Healthcare Provider Details

I. General information

NPI: 1568444305
Provider Name (Legal Business Name): DAVID J GRAY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6491 PEACHTREE INDUSTRIAL BLVD
ATLANTA GA
30360-2100
US

IV. Provider business mailing address

6491 PEACHTREE INDUSTRIAL BLVD
ATLANTA GA
30360-2100
US

V. Phone/Fax

Practice location:
  • Phone: 770-689-1858
  • Fax:
Mailing address:
  • Phone: 770-689-1858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number25672
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number282282
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number23405
License Number StateMS
# 4
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number87355
License Number StateGA
# 5
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number2017001968
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: