Provider Demographics
NPI:1366551970
Name:GRAY, JEFFREY WAYNE (PHD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:WAYNE
Last Name:GRAY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 BELLEMEADE AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-2062
Mailing Address - Country:US
Mailing Address - Phone:812-477-0407
Mailing Address - Fax:
Practice Address - Street 1:1450 BELLEMEADE AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-2062
Practice Address - Country:US
Practice Address - Phone:812-477-0407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040332174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INR34350Medicare UPIN
IN839420Medicare ID - Type Unspecified