Healthcare Provider Details

I. General information

NPI: 1821028127
Provider Name (Legal Business Name): JOHN R. GRAY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 04/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 BATTLEFIELD MALL SPRINGFIELD EYECARE, LLC
SPRINGFIELD MO
65804
US

IV. Provider business mailing address

113 BATTLEFIELD MALL SPRINGFIELD EYECARE LLC
SPRINGFIELD MO
65804
US

V. Phone/Fax

Practice location:
  • Phone: 417-887-6883
  • Fax: 417-887-6884
Mailing address:
  • Phone: 417-887-6883
  • Fax: 417-887-6884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTO2165
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: