Basic Information
Provider Information | |||||||||
NPI: | 1669009197 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRAY | ||||||||
FirstName: | LAWRENCE | ||||||||
MiddleName: | CHARLES | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | II | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1028 CYPRESS POINTE DR | ||||||||
Address2: |   | ||||||||
City: | CASEYVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 622322830 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6185316222 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3551 ROGER BROOKE DR | ||||||||
Address2: |   | ||||||||
City: | FORT SAM HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 782344504 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2109168666 | ||||||||
FaxNumber: | 2109168712 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/25/2020 | ||||||||
LastUpdateDate: | 05/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 208D00000X | 0101275124 | VA | Y |   | Allopathic & Osteopathic Physicians | General Practice |   |
No ID Information.