Provider Demographics
NPI:1043233760
Name:GRANT, ELLSWORTH RAYMOND (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLSWORTH
Middle Name:RAYMOND
Last Name:GRANT
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 1:1245 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 801
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-4810
Mailing Address - Country:US
Mailing Address - Phone:213-481-3948
Mailing Address - Fax:213-481-1697
Practice Address - Street 1:1245 WILSHIRE BLVD
Practice Address - Street 2:SUITE 801
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-4810
Practice Address - Country:US
Practice Address - Phone:213-481-3948
Practice Address - Fax:213-481-1697
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73084207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA954893061OtherTAX ID NO.
CA00G730841Medicaid
CA00G730842Medicaid
CA00G730842Medicaid
CABG9701601OtherDEA NO. HOPE ST.
CABG3056012OtherDEA NO. WILSHIRE
CAG73084AMedicare ID - Type UnspecifiedHOPE ST. OFFICE
CAG73084Medicare ID - Type UnspecifiedWILSHIRE OFFICE