Healthcare Provider Details

I. General information

NPI: 1750950440
Provider Name (Legal Business Name): HARRISON MICHAEL GRAY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2021
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3550 N UNIVERSITY AVE STE 250
PROVO UT
84604-6695
US

IV. Provider business mailing address

3550 N UNIVERSITY AVE STE 250
PROVO UT
84604-6695
US

V. Phone/Fax

Practice location:
  • Phone: 801-374-9625
  • Fax: 801-374-9690
Mailing address:
  • Phone: 801-374-9625
  • Fax: 801-374-9690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number8849808-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: