Basic Information
| Provider Information | |||||||||
| NPI: | 1588633499 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WRAY | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WRAY | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | JANE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D., PHD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 111 S LAUREL AVE | ||||||||
| Address2: | |||||||||
| City: | LULING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786482624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8308756399 | ||||||||
| FaxNumber: | 8558252552 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 S LAUREL AVE | ||||||||
| Address2: | |||||||||
| City: | LULING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786482624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8308756399 | ||||||||
| FaxNumber: | 8308756398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 01/10/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | G4757 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 2080P0205X | G4757 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology |
ID Information
| ID | Type | State | Issuer | Description | 0074KV | 01 | TX | BCBS PROVIDER ID | OTHER | 137109801 | 05 | TX | MEDICAID |