Provider Demographics
NPI:1912662206
Name:GRAY-COATS, DOMINIQUE MAURICE
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:MAURICE
Last Name:GRAY-COATS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6005 VALERIE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72118-3180
Mailing Address - Country:US
Mailing Address - Phone:501-612-4068
Mailing Address - Fax:
Practice Address - Street 1:2501 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72206-2149
Practice Address - Country:US
Practice Address - Phone:501-612-4068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-02
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR87-3371255OtherNONE