Provider Demographics
NPI:1528089513
Name:GRAY, VICTOR JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:JOHN
Last Name:GRAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2439
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803-2439
Mailing Address - Country:US
Mailing Address - Phone:662-842-4919
Mailing Address - Fax:662-842-9140
Practice Address - Street 1:218 S THOMAS ST
Practice Address - Street 2:SUITE 110
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-5330
Practice Address - Country:US
Practice Address - Phone:662-842-4919
Practice Address - Fax:662-842-9140
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS15561208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
H35425Medicare UPIN
MS250000046Medicare ID - Type Unspecified