Basic Information
| Provider Information | |||||||||
| NPI: | 1689855967 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ANDREA V GRAY MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2569 NW EDENBOWER BLVD | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419575400 | ||||||||
| FaxNumber: | 5414401010 | ||||||||
| Practice Location | |||||||||
| Address1: | 2569 NW EDENBOWER BLVD | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419575400 | ||||||||
| FaxNumber: | 5414401010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2007 | ||||||||
| LastUpdateDate: | 11/15/2007 | ||||||||
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| AuthorizedOfficialLastName: | GRAY | ||||||||
| AuthorizedOfficialFirstName: | ANDREA | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5419575400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | OR | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
ID Information
| ID | Type | State | Issuer | Description | 4373040001 | 01 | OR | DMERC | OTHER |