Basic Information
| Provider Information | |||||||||
| NPI: | 1851383343 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | STANLEY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1571 WASHINGTON ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136019304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157865046 | ||||||||
| FaxNumber: | 3157865043 | ||||||||
| Practice Location | |||||||||
| Address1: | 1571 WASHINGTON ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136019304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157865000 | ||||||||
| FaxNumber: | 3157865040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2005 | ||||||||
| LastUpdateDate: | 10/16/2019 | ||||||||
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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 | 2085R0203X | 206039-1 | NY | N | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology | 2085R0202X | 206039-1 | NY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 01747204 | 05 | NY | MEDICAID |