Provider Demographics
NPI:1992276471
Name:GRAYSON, ROGER DALE II
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:DALE
Last Name:GRAYSON
Suffix:II
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 1:801 PRAIRIE ST
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71295-2631
Mailing Address - Country:US
Mailing Address - Phone:318-435-4140
Mailing Address - Fax:
Practice Address - Street 1:801 PRAIRIE ST
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295-2631
Practice Address - Country:US
Practice Address - Phone:318-435-4140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-10
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA320306488332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2118218Medicaid