1033257019 NPI number — DR. HARRY EDWARD GRAY III O.D., PH.D.

Table of content: DR. MATTHEW EVERT WIISANEN MD (NPI 1215945001)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033257019 NPI number — DR. HARRY EDWARD GRAY III O.D., PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAY
Provider First Name:
HARRY
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
O.D., PH.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033257019
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
74 LOWRIE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTHFIELD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44067-1272
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-467-0255
Provider Business Mailing Address Fax Number:
330-467-0255

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5100 GREAT NORTHERN MALL
Provider Second Line Business Practice Location Address:
JC PENNEY OPTICAL
Provider Business Practice Location Address City Name:
NORTH OLMSTED
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44070-3305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-779-8145
Provider Business Practice Location Address Fax Number:
440-779-9118
Provider Enumeration Date:
02/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  5212 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2274462 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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