Basic Information
| Provider Information | |||||||||
| NPI: | 1023046828 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRAY | ||||||||
| FirstName: | DARREN | ||||||||
| MiddleName: | DALE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5550 S EAST ST STE C | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462271991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175344660 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5550 S EAST ST STE C | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462271991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175344660 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 06/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 50611 | MN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1023046828 | 05 | MN | MEDICAID | 1851337356 | 05 | CA | MEDICAID |