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General NPI Number Information
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NPI Number | 1477585396
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Entity Type | Individual
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Provider Name | JASON D GRAY D.P.M.
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Gender | Male
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Dates
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Enumeration Date | 07/07/2006
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Last Update Date | 02/09/2021
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Provider Practice Location Address
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Address Line | 330 N WABASH AVE STE 460A
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City | MARION
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State | IN
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Zip | 46952-2685
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Country | US
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Telephone | 765-664-1413
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Fax | 765-664-2836
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Provider Business Mailing Address
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Address Line | PO BOX 330
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City | FORTVILLE
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State | IN
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Zip | 46040-0330
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Country | US
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Telephone | 317-863-2556
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Fax | 317-203-0420
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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 | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 07000998A
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License Number State | IN
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