Basic Information
Provider Information | |||||||||
NPI: | 1841494465 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRAY | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KOVAL | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 835 E 18TH AVE STE 110 | ||||||||
Address2: |   | ||||||||
City: | DENVER | ||||||||
State: | CO | ||||||||
PostalCode: | 802181024 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3038254646 | ||||||||
FaxNumber: | 3038253215 | ||||||||
Practice Location | |||||||||
Address1: | 835 E 18TH AVE STE 110 | ||||||||
Address2: |   | ||||||||
City: | DENVER | ||||||||
State: | CO | ||||||||
PostalCode: | 80218 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3038254646 | ||||||||
FaxNumber: | 3038253215 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2007 | ||||||||
LastUpdateDate: | 10/10/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/10/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 01069712A | IN | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 207R00000X | 01069712A | IN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | DR.0053894 | CO | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 201027670 | 05 | IN |   | MEDICAID |