Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 125-056918 | IL |
Y | 207Q00000X | Family Doctor | 824 | NE |
NPI | 1003044421 |
---|---|
Provider Name | Dr. Richard E Gray |
First Address | Apo, AP 96328-5071 |
Second Address | Apo, AE 09461-5115 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/06/2009 |
Last Update Date | 11/08/2020 |