Provider Demographics
NPI:1508200833
Name:GRANGE, JACOB STUART (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:STUART
Last Name:GRANGE
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 1:1032 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7027
Mailing Address - Country:US
Mailing Address - Phone:541-770-4559
Mailing Address - Fax:541-770-4511
Practice Address - Street 1:1032 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504
Practice Address - Country:US
Practice Address - Phone:541-770-4559
Practice Address - Fax:541-770-4511
Is Sole Proprietor?:No
Enumeration Date:2013-04-17
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116026086390200000X
ORMD186209207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program