Healthcare Provider Details

I. General information

NPI: 1639284623
Provider Name (Legal Business Name): JOHN D GRAY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1881 CHICAGO ST
DEPERE WI
54115
US

IV. Provider business mailing address

3301 W FOREST HOME AVE
MILWAUKEE WI
53215-2843
US

V. Phone/Fax

Practice location:
  • Phone: 920-403-8000
  • Fax: 920-403-8202
Mailing address:
  • Phone: 414-647-6326
  • Fax: 414-671-8860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number27644
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: