Provider Demographics
NPI:1124324744
Name:GRAY, MELANIE (DO)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:GRAY
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W CANNON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3029
Mailing Address - Country:US
Mailing Address - Phone:817-877-5858
Mailing Address - Fax:817-335-4418
Practice Address - Street 1:3101 CHURCHILL DR STE 115
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75022-2717
Practice Address - Country:US
Practice Address - Phone:469-645-1804
Practice Address - Fax:817-725-7885
Is Sole Proprietor?:No
Enumeration Date:2011-01-28
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP9861207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX354166601Medicaid