Basic Information
Provider Information | |||||||||
NPI: | 1366435729 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRAY | ||||||||
FirstName: | DANIEL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | OD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7100 SIX FORKS RD | ||||||||
Address2: | SUITE 301 | ||||||||
City: | RALEIGH | ||||||||
State: | NC | ||||||||
PostalCode: | 276156156 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9198470187 | ||||||||
FaxNumber: | 9196762231 | ||||||||
Practice Location | |||||||||
Address1: | 1975 HIGH HOUSE RD | ||||||||
Address2: |   | ||||||||
City: | CARY | ||||||||
State: | NC | ||||||||
PostalCode: | 275198452 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9194610771 | ||||||||
FaxNumber: | 9194810645 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2005 | ||||||||
LastUpdateDate: | 02/12/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1861 | NC | Y |   | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | P00010416 | 01 | NC | RAILROAD MEDICARE | OTHER | 133PT | 01 | NC | BLUECROSS | OTHER | 89133PT | 05 | NC |   | MEDICAID |