Provider Demographics
NPI:1679782411
Name:SCOTT K GRAY DPM PA
Entity type:Organization
Organization Name:SCOTT K GRAY DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:K
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:870-536-3669
Mailing Address - Street 1:8604 DOLLARWAY RD
Mailing Address - Street 2:
Mailing Address - City:WHITE HALL
Mailing Address - State:AR
Mailing Address - Zip Code:71602-2814
Mailing Address - Country:US
Mailing Address - Phone:870-536-3669
Mailing Address - Fax:870-536-0149
Practice Address - Street 1:8604 DOLLARWAY RD
Practice Address - Street 2:
Practice Address - City:WHITE HALL
Practice Address - State:AR
Practice Address - Zip Code:71602-2814
Practice Address - Country:US
Practice Address - Phone:870-536-3669
Practice Address - Fax:870-536-0149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR197213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR152076716Medicaid
AR5F841OtherBCBS
AR5F841Medicare PIN
6177040001Medicare NSC
ARU89815Medicare UPIN
AR152076716Medicaid
ARDN9982Medicare PIN