Provider Demographics
NPI:1942208855
Name:GRAY, PATRICK WALLACE (MD)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:WALLACE
Last Name:GRAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 FAIRVIEW AVE
Mailing Address - Street 2:SUITE 17
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-1910
Mailing Address - Country:US
Mailing Address - Phone:580-762-3696
Mailing Address - Fax:580-765-0675
Practice Address - Street 1:400 FAIRVIEW AVE
Practice Address - Street 2:SUITE 17
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-1910
Practice Address - Country:US
Practice Address - Phone:580-762-3696
Practice Address - Fax:580-765-0675
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15395207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
4580447418Medicare ID - Type Unspecified
B69286Medicare UPIN