Provider Demographics
NPI:1073710992
Name:WHITTAKER, GRANT TYLER (MD)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:TYLER
Last Name:WHITTAKER
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 1:4800 BELFORT RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1348 SOUTH 18TH STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4755
Practice Address - Country:US
Practice Address - Phone:904-261-0879
Practice Address - Fax:904-277-7054
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD 30868207R00000X
FLME 105816207R00000X
FLME105816207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine