=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831651447
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALAN JAMES GRAY MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2019
-----------------------------------------------------
Last Update Date | 11/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 868 E RIVERSIDE DR STE 170
-----------------------------------------------------
City | EAGLE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83616-6025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-918-2416
-----------------------------------------------------
Fax | 208-203-8644
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 868 E RIVERSIDE DR STE 170
-----------------------------------------------------
City | EAGLE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83616-6025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-918-2416
-----------------------------------------------------
Fax | 208-203-8644
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207YS0123X
-----------------------------------------------------
Taxonomy Name | Facial Plastic Surgery Physician
-----------------------------------------------------
License Number | 3271959
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------