Provider Demographics
NPI:1326667346
Name:JIRKA, GRANT WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:WILLIAM
Last Name:JIRKA
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 1:1441 EASTLAKE AVE # NTT3440
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90089-4405
Mailing Address - Country:US
Mailing Address - Phone:323-865-3823
Mailing Address - Fax:
Practice Address - Street 1:1441 EASTLAKE AVE # NTT3440
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-4405
Practice Address - Country:US
Practice Address - Phone:323-865-3823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-09
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT220309207R00000X
CA187091207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine