Provider Demographics
NPI:1659029205
Name:GOODFELLOW, GRANT CONNOR (DO)
Entity Type:Individual
Prefix:MR
First Name:GRANT
Middle Name:CONNOR
Last Name:GOODFELLOW
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30117 SCHOENHERR RD STE 400
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-6854
Mailing Address - Country:US
Mailing Address - Phone:586-738-9470
Mailing Address - Fax:
Practice Address - Street 1:30117 SCHOENHERR RD STE 400
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-6854
Practice Address - Country:US
Practice Address - Phone:586-738-9470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-14
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program