Provider Demographics
NPI:1205839537
Name:MCMAHAN, GRADY MARK (DO)
Entity Type:Individual
Prefix:
First Name:GRADY
Middle Name:MARK
Last Name:MCMAHAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:GRADY
Other - Middle Name:MARK
Other - Last Name:MCMAHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:4101 WESLEY ST
Mailing Address - Street 2:STE C
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75401-5635
Mailing Address - Country:US
Mailing Address - Phone:903-454-8111
Mailing Address - Fax:903-454-1680
Practice Address - Street 1:4101 WESLEY ST
Practice Address - Street 2:STE C
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75401-5635
Practice Address - Country:US
Practice Address - Phone:903-454-8111
Practice Address - Fax:903-454-1680
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6584207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00217687OtherRAILROAD MEDICARE
TX8J1203OtherBCBS OF TEXAS
TXP00217687OtherRAILROAD MEDICARE
TX8C6046Medicare ID - Type Unspecified