Provider Demographics
NPI:1346762903
Name:GRANT D. SHIFFLETT, MD INC
Entity Type:Organization
Organization Name:GRANT D. SHIFFLETT, MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:SHIFFLETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-574-0400
Mailing Address - Street 1:13160 MINDANAO WAY STE 170
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6393
Mailing Address - Country:US
Mailing Address - Phone:310-881-3688
Mailing Address - Fax:
Practice Address - Street 1:13160 MINDANAO WAY STE 300
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6393
Practice Address - Country:US
Practice Address - Phone:310-574-0400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-14
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA143697207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty