Provider Demographics
NPI:1104818020
Name:GRAY, ANDREA V (MD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:V
Last Name:GRAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2995 NW EDENBOWER BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-6209
Mailing Address - Country:US
Mailing Address - Phone:541-957-5400
Mailing Address - Fax:541-440-1010
Practice Address - Street 1:2995 NW EDENBOWER BLVD
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-6209
Practice Address - Country:US
Practice Address - Phone:541-957-5400
Practice Address - Fax:541-440-1010
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD21540207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORG93145Medicare UPIN
ORR109648Medicare PIN