Provider Demographics
NPI:1588789382
Name:GRAY, TERRY GLENN JR (SFIDC)
Entity type:Individual
Prefix:MR
First Name:TERRY
Middle Name:GLENN
Last Name:GRAY
Suffix:JR
Gender:M
Credentials:SFIDC
Other - Prefix:
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Mailing Address - Street 1:263 WITCHTROT RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BERWICK
Mailing Address - State:ME
Mailing Address - Zip Code:03908-2167
Mailing Address - Country:US
Mailing Address - Phone:207-457-5442
Mailing Address - Fax:207-438-1987
Practice Address - Street 1:ONE AYERS CIRCLE, BUILDING H-1
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03904-5000
Practice Address - Country:US
Practice Address - Phone:207-438-4940
Practice Address - Fax:207-498-1987
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman