MEDICARE: MR. JUSTIN DORIAN GREY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084F0202X	Forensic Psychiatry Physician	G65957	CA
2	2084P0800X	Psychiatry Physician	G65957	CA
3	2084P0802X	Addiction Psychiatry Physician	G65957	CA
4	2084P0804X	Child & Adolescent Psychiatry Physician	G65957	CA
5	2084P0805X	Geriatric Psychiatry Physician	G65957	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00G659571	OTHER		PPIN

General Provider Information

NPI Number	:	1992898753
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JUSTIN DORIAN GREY MD

Provider Business Mailing Address
First Line	:	2001 THE ALAMEDA
Second Line	:	ALLIANCE FOR COMMUNITY CARE
City	:	SAN JOSE
State	:	CA
Zip	:	95126-1136
Country	:	US
Telephone Number	:	408-261-7777
Fax Number	:	408-554-9960

Provider Business Practice Location Address
First Line	:	2001 THE ALAMEDA
Second Line	:	ALLIANCE FOR COMMUNITY CARE
City	:	SAN JOSE
State	:	CA
Zip	:	95126-1136
Country	:	US
Telephone Number	:	408-261-7777
Fax Number	:	408-554-9960

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	03/19/2008

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