Provider Demographics
NPI:1427486778
Name:GRAY, KENNETH C SR (PHD,MD, ND)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:C
Last Name:GRAY
Suffix:SR
Gender:M
Credentials:PHD,MD, ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 MALLVIEW LN
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-2974
Mailing Address - Country:US
Mailing Address - Phone:630-914-5065
Mailing Address - Fax:
Practice Address - Street 1:451 MALLVIEW LN
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-2974
Practice Address - Country:US
Practice Address - Phone:630-914-5065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-24
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL175F00000X, 246RP1900X, 247ZC0005X, 175F00000X
367H00000X, 174H00000X, 1710I1002X, 172A00000X, 175L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician
No367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No174H00000XOther Service ProvidersHealth Educator
No1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
No172A00000XOther Service ProvidersDriver
No175L00000XOther Service ProvidersHomeopath