Healthcare Provider Details

I. General information

NPI: 1215958715
Provider Name (Legal Business Name): JOHN GRAY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WYOMING ST STE 4130
DAYTON OH
45409-2722
US

IV. Provider business mailing address

100 N ACADEMY AVE # MC2770
DANVILLE PA
17822-0001
US

V. Phone/Fax

Practice location:
  • Phone: 937-438-8640
  • Fax: 937-438-7251
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number9501257
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMD434078
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number8971137
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: