Basic Information
| Provider Information | |||||||||
| NPI: | 1932652351 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAYSON | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2049 NIAGARA ST | ||||||||
| Address2: | |||||||||
| City: | WINDSOR | ||||||||
| State: | ON | ||||||||
| PostalCode: | N8Y1K4 | ||||||||
| CountryCode: | CA | ||||||||
| TelephoneNumber: | 6478893734 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4201 SAINT ANTOINE ST | ||||||||
| Address2: | UHC-9C | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137455146 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2016 | ||||||||
| LastUpdateDate: | 08/02/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.