Healthcare Provider Details

I. General information

NPI: 1528309911
Provider Name (Legal Business Name): SHAKETHA ACQUINETTA GRAY M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2013
Last Update Date: 04/20/2022
Certification Date: 04/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N MARTIN LUTHER KING JR DR
WINSTON SALEM NC
27101-3006
US

IV. Provider business mailing address

100 KIMEL FOREST DR
WINSTON SALEM NC
27103-6074
US

V. Phone/Fax

Practice location:
  • Phone: 336-713-9800
  • Fax: 336-713-9641
Mailing address:
  • Phone: 336-716-0238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberME136832
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2022-00459
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: