Provider Demographics
NPI:1588664908
Name:GRAY, ANDY JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:ANDY
Middle Name:JOHN
Last Name:GRAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3719 22ND ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1329
Mailing Address - Country:US
Mailing Address - Phone:806-785-0600
Mailing Address - Fax:806-785-0606
Practice Address - Street 1:3719 22ND ST
Practice Address - Street 2:STE.B
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1329
Practice Address - Country:US
Practice Address - Phone:806-785-0600
Practice Address - Fax:806-785-0606
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH3061173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB87968Medicare UPIN
TXB87968Medicare UPIN