Provider Demographics
NPI:1053305334
Name:NAKAMURA, GRANT JIRO (MD)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:JIRO
Last Name:NAKAMURA
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:PO BOX 28949
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93729-8949
Mailing Address - Country:US
Mailing Address - Phone:559-228-4200
Mailing Address - Fax:559-224-3920
Practice Address - Street 1:923 G ST
Practice Address - Street 2:
Practice Address - City:REEDLEY
Practice Address - State:CA
Practice Address - Zip Code:93654-2626
Practice Address - Country:US
Practice Address - Phone:559-637-1050
Practice Address - Fax:559-637-1476
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG50552207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G505520Medicaid
CA00G505526Medicare PIN
CA080094169Medicare PIN
CA00G505520Medicaid
CA00G505520Medicare PIN