Provider Demographics
NPI:1629745658
Name:GRADY, JHONNY D
Entity Type:Individual
Prefix:
First Name:JHONNY
Middle Name:D
Last Name:GRADY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5839 N TEUTONIA AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-4161
Mailing Address - Country:US
Mailing Address - Phone:917-719-4698
Mailing Address - Fax:
Practice Address - Street 1:5839 N TEUTONIA AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-4161
Practice Address - Country:US
Practice Address - Phone:917-719-4698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIG6304246825900
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIG6304246825900Medicaid