Provider Demographics
NPI:1376785600
Name:DOORNBOS, GRANT ADAM (MD)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:ADAM
Last Name:DOORNBOS
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 1:3804 GLENGARRY WAY NE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-2615
Mailing Address - Country:US
Mailing Address - Phone:404-245-3687
Mailing Address - Fax:
Practice Address - Street 1:1300 RIDENOUR BLVD NW STE 300
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-4402
Practice Address - Country:US
Practice Address - Phone:770-702-1806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-01
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA069398207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology