Provider Demographics
NPI:1477567345
Name:GRADY, SHAUN P (MD)
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:P
Last Name:GRADY
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 1:207 S SANTA ANITA ST
Mailing Address - Street 2:SUITE 335
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776
Mailing Address - Country:US
Mailing Address - Phone:626-576-1214
Mailing Address - Fax:626-458-3387
Practice Address - Street 1:207 S SANTA ANITA ST
Practice Address - Street 2:SUITE 335
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776
Practice Address - Country:US
Practice Address - Phone:626-576-1214
Practice Address - Fax:626-458-3387
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG70152207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G701520Medicaid
CAG70152BMedicare ID - Type Unspecified
CA00G701520Medicaid