Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208000000X | Pediatrician | 52536 | WI |
NPI | 1013030220 |
---|---|
Provider Name | Matthew Philip Gray |
First Address | Milwaukee, WI 53226-4874 |
Second Address | Milwaukee, WI 53226-4874 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/04/2007 |
Last Update Date | 11/10/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1013030220 | (05) | WI |