Healthcare Provider Details

I. General information

NPI: 1942202288
Provider Name (Legal Business Name): DENNIS S GRAY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1169 EASTERN PKWY STE 1111
LOUISVILLE KY
40217-1462
US

IV. Provider business mailing address

1169 EASTERN PKWY STE 1111
LOUISVILLE KY
40217-1462
US

V. Phone/Fax

Practice location:
  • Phone: 502-456-4100
  • Fax: 502-459-8454
Mailing address:
  • Phone: 502-456-4100
  • Fax: 502-459-8454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21462
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: