Healthcare Provider Details

I. General information

NPI: 1477539252
Provider Name (Legal Business Name): SHARMANE MARIE GRAY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 03/16/2022
Certification Date: 03/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1572 GA 85 STE 209
FAYETTEVILLE GA
30214-1998
US

IV. Provider business mailing address

1572 GA 85 STE 209
FAYETTEVILLE GA
30214-1998
US

V. Phone/Fax

Practice location:
  • Phone: 470-402-9409
  • Fax: 470-558-2898
Mailing address:
  • Phone: 470-402-9409
  • Fax: 470-558-2898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC132774
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number12913
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number01054888A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number84917
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: