Provider Demographics
NPI:1669411773
Name:RAY, P TRUETT JR (MD)
Entity type:Individual
Prefix:
First Name:P
Middle Name:TRUETT
Last Name:RAY
Suffix:JR
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 1:504 N ACADIA RD
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-4862
Mailing Address - Country:US
Mailing Address - Phone:985-447-5667
Mailing Address - Fax:985-447-5670
Practice Address - Street 1:504 N ACADIA RD
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4862
Practice Address - Country:US
Practice Address - Phone:985-447-5667
Practice Address - Fax:985-447-5670
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD013941208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1333948Medicaid
LA4397691627AOtherBLUE CROSS BLUE SHIELD
LAP00065497OtherRAILROAD MEDICARE
LA4397691627AOtherBLUE CROSS BLUE SHIELD
LA54902Medicare ID - Type Unspecified