Provider Demographics
NPI:1013548486
Name:NEUGIN, GRANT DAVID
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:DAVID
Last Name:NEUGIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22758 S 494 RD
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-1631
Mailing Address - Country:US
Mailing Address - Phone:918-772-0696
Mailing Address - Fax:
Practice Address - Street 1:22758 S 494 RD
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-1631
Practice Address - Country:US
Practice Address - Phone:918-772-0696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator