Provider Demographics
NPI:1124109806
Name:FENTON, GRAY MATTHEW (DO)
Entity type:Individual
Prefix:MR
First Name:GRAY
Middle Name:MATTHEW
Last Name:FENTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:8320 W SUNRISE BLVD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33322-5435
Mailing Address - Country:US
Mailing Address - Phone:954-838-7200
Mailing Address - Fax:954-838-9192
Practice Address - Street 1:12651 W SUNRISE BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-0906
Practice Address - Country:US
Practice Address - Phone:954-838-7200
Practice Address - Fax:954-838-9192
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2008-11-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLOS7890207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL46644Medicare ID - Type Unspecified
FLG93587Medicare UPIN