Provider Demographics
NPI:1528309911
Name:GRAY, SHAKETHA ACQUINETTA (MD)
Entity type:Individual
Prefix:DR
First Name:SHAKETHA
Middle Name:ACQUINETTA
Last Name:GRAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-716-0238
Mailing Address - Fax:
Practice Address - Street 1:1200 N MARTIN LUTHER KING JR DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-3006
Practice Address - Country:US
Practice Address - Phone:336-713-9800
Practice Address - Fax:336-713-9641
Is Sole Proprietor?:No
Enumeration Date:2013-03-08
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1368322080A0000X
NC2022-00459208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine