Healthcare Provider Details

I. General information

NPI: 1497729826
Provider Name (Legal Business Name): GARY D GRAY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 12/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5551 WINGHAVEN BLVD STE 290
O FALLON MO
63368-3617
US

IV. Provider business mailing address

5551 WINGHAVEN BLVD STE 290
O FALLON MO
63368-3617
US

V. Phone/Fax

Practice location:
  • Phone: 636-695-2575
  • Fax: 314-590-5938
Mailing address:
  • Phone: 636-695-2575
  • Fax: 314-590-5938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2001028980
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: