Healthcare Provider Details

I. General information

NPI: 1073048492
Provider Name (Legal Business Name): GRAYSON JEFFREY KOVAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2017
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 N A ST STE 110
MIDLAND TX
79705-5421
US

IV. Provider business mailing address

3419 22ND ST
LUBBOCK TX
79410-1334
US

V. Phone/Fax

Practice location:
  • Phone: 432-400-3401
  • Fax: 432-400-3402
Mailing address:
  • Phone: 806-796-3000
  • Fax: 806-796-3006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberT5364
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: