Provider Demographics
NPI:1366544108
Name:GRAY, MARTHA JEAN (RD)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:JEAN
Last Name:GRAY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2742 DOW AVE
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-7242
Mailing Address - Country:US
Mailing Address - Phone:714-665-1600
Mailing Address - Fax:
Practice Address - Street 1:26991 CROWN VALLEY PKWY
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6528
Practice Address - Country:US
Practice Address - Phone:949-582-2002
Practice Address - Fax:949-367-5200
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNR166117133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWNT166117AMedicare PIN
CACQ306YMedicare PIN