Provider Demographics
NPI:1184088486
Name:GRAY, SAMUEL (DPM)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:GRAY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:MR
Other - First Name:SAMUEL
Other - Middle Name:THOMAS
Other - Last Name:GAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7850 NEWPORT GLEN PASS
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-1561
Mailing Address - Country:US
Mailing Address - Phone:917-238-0909
Mailing Address - Fax:
Practice Address - Street 1:46090 LAKE CENTER PLZ STE 204
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20165-5878
Practice Address - Country:US
Practice Address - Phone:703-539-2036
Practice Address - Fax:703-563-2716
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103301267213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery