Provider Demographics
NPI:1568457265
Name:GRANTHAM, ROY N (MD)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:N
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 1:3545 NW 58TH ST
Mailing Address - Street 2:450
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-4726
Mailing Address - Country:US
Mailing Address - Phone:405-951-4360
Mailing Address - Fax:866-857-2543
Practice Address - Street 1:4221 S WESTERN AVE
Practice Address - Street 2:2010
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-3447
Practice Address - Country:US
Practice Address - Phone:405-231-0540
Practice Address - Fax:405-644-5309
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK164652086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK5765290OtherAETNA
060052653OtherRAILROAD MEDICARE
OK100122170AMedicaid
OK125309100OtherDOL
OK5765290OtherAETNA
OK365531YSGZMedicare PIN