Healthcare Provider Details

I. General information

NPI: 1932128477
Provider Name (Legal Business Name): KEVIN DAVID GRAYSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 SUNSET DR
LA GRANDE OR
97850-1248
US

IV. Provider business mailing address

612 SUNSET DR
LA GRANDE OR
97850-1248
US

V. Phone/Fax

Practice location:
  • Phone: 541-663-3150
  • Fax: 541-975-5111
Mailing address:
  • Phone: 541-663-3150
  • Fax: 541-975-5111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD23354
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: