Provider Demographics
NPI:1386671238
Name:GRANTHAM, JONATHAN L (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:L
Last Name:GRANTHAM
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:PO BOX 2546
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-2546
Mailing Address - Country:US
Mailing Address - Phone:620-783-4441
Mailing Address - Fax:620-783-4090
Practice Address - Street 1:444 FOUR STATES DR
Practice Address - Street 2:SUITE 1
Practice Address - City:GALENA
Practice Address - State:KS
Practice Address - Zip Code:66739-4324
Practice Address - Country:US
Practice Address - Phone:620-783-4441
Practice Address - Fax:620-783-4090
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO107822207X00000X
KS0433509207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207974510Medicaid
KS100404800GMedicaid
KS100404800CMedicaid
KSKA1177008Medicare PIN
H45897Medicare UPIN
MO963535141Medicare PIN