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General NPI Number Information
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NPI Number | 1265497333
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Entity Type | Individual
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Provider Name | JOHN B GRAY MD
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Gender | Male
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Dates
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Enumeration Date | 04/20/2006
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Last Update Date | 07/20/2020
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Provider Practice Location Address
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Address Line | 801 POLE LINE RD W
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City | TWIN FALLS
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State | ID
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Zip | 83301-5810
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Country | US
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Telephone | 208-814-0364
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 553
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City | TWIN FALLS
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State | ID
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Zip | 83303-0553
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Country | US
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Telephone | 208-736-0887
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ZP0102X
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Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
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License Number | M-4393
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License Number State | ID
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