Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152WC0802X | Optomitrist - Corneal and Contact Lenses | IL | |
N | 152WP0200X | Pediatric Optomitrist | IL |
NPI | 1275603672 |
---|---|
Provider Name | Gary G Gray |
First Address | Decatur, IL 62526-4251 |
Second Address | Decatur, IL 62526-4251 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/11/2006 |
Last Update Date | 20/11/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0159620001 | DMERC ADMINISTAR (01) | IL |
4056086 | BCBCS (01) | TN |
5884008 | BCBS (01) | IL |
6259G | UNITED HEALTHCARE (01) | IL |
T37689 | (02) |