Healthcare Provider Details

I. General information

NPI: 1275603672
Provider Name (Legal Business Name): GARY G GRAY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 11/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2490 N WATER ST SUITE 16
DECATUR IL
62526-4251
US

IV. Provider business mailing address

2490 N WATER ST SUITE 16
DECATUR IL
62526-4251
US

V. Phone/Fax

Practice location:
  • Phone: 217-875-4646
  • Fax: 217-875-2870
Mailing address:
  • Phone: 217-875-4646
  • Fax: 217-875-2870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: