Basic Information
| Provider Information | |||||||||
| NPI: | 1548404783 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | OPTICIAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 973 | ||||||||
| Address2: | |||||||||
| City: | LUSBY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206570973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016720315 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3005 LEONARDTOWN RD | ||||||||
| Address2: | |||||||||
| City: | WALDORF | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206013136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016456550 | ||||||||
| FaxNumber: | 3016456699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2009 | ||||||||
| LastUpdateDate: | 04/30/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X | Y | Eye and Vision Services Providers | Technician/Technologist | Optician |
No ID Information.