Basic Information
| Provider Information | |||||||||
| NPI: | 1881600732 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1266 | ||||||||
| Address2: | |||||||||
| City: | KAILUA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967341266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082613326 | ||||||||
| FaxNumber: | 8082634604 | ||||||||
| Practice Location | |||||||||
| Address1: | 1190 WAIANUENUE AVE | ||||||||
| Address2: | |||||||||
| City: | HILO | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967202020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082613326 | ||||||||
| FaxNumber: | 8082634604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207P00000X | G4461 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | MD-12017 | HI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 535932 | 05 | HI | MEDICAID | 8A9550 | 01 | TX | BLUECROSS BLUESHIELD | OTHER | 0000240366 | 01 | HI | HMSA | OTHER |