Provider Demographics
NPI:1609034040
Name:GRANTHAM, JEFFREY SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:SCOTT
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 1:1620 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74120-5407
Mailing Address - Country:US
Mailing Address - Phone:918-588-8890
Mailing Address - Fax:
Practice Address - Street 1:1620 E 12TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-5407
Practice Address - Country:US
Practice Address - Phone:918-588-8890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-31
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK290242084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry