Provider Demographics
NPI:1396372405
Name:VAN DER VOORT, GRANT MCLEOD (MD)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:MCLEOD
Last Name:VAN DER VOORT
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:ACADEMIC OFFICE ONE BLDG., ROOM #5602
Mailing Address - Street 2:12631 EAST 17TH AVE., M/S C-319
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80045
Mailing Address - Country:US
Mailing Address - Phone:303-724-2715
Mailing Address - Fax:303-724-2818
Practice Address - Street 1:12605 E 16TH AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-2545
Practice Address - Country:US
Practice Address - Phone:720-848-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COTL.0007995390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program