Basic Information
| Provider Information | |||||||||
| NPI: | 1285813436 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHN P GRAY MD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4100 INTERNATIONAL PLAZA | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761094823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173340530 | ||||||||
| FaxNumber: | 8178770350 | ||||||||
| Practice Location | |||||||||
| Address1: | 1204 N MOUND ST | ||||||||
| Address2: | |||||||||
| City: | NACOGDOCHES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759614027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9364627844 | ||||||||
| FaxNumber: | 9364627855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2007 | ||||||||
| LastUpdateDate: | 08/28/2014 | ||||||||
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| AuthorizedOfficialLastName: | GRAY | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9366751065 | ||||||||
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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 | 207L00000X | K7025 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 180299301 | 05 | TX | MEDICAID | 0046NA | 01 | TX | BC/BS | OTHER | 0046NA | 01 | TX | BCBS | OTHER |