Provider Demographics
NPI:1528120714
Name:GRAY, DIANE M (OD)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:GRAY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 844
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59624-0844
Mailing Address - Country:US
Mailing Address - Phone:406-442-6814
Mailing Address - Fax:406-443-7732
Practice Address - Street 1:534 N LAST CHANCE GULCH ST
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-3303
Practice Address - Country:US
Practice Address - Phone:406-442-6814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT432152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0480441Medicaid
MTT89232Medicare UPIN
MT0480441Medicaid