Provider Demographics
NPI:1659460574
Name:GRIM, JONATHAN EZRA (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:EZRA
Last Name:GRIM
Suffix:
Gender:M
Credentials:MD, PHD
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Mailing Address - Street 1:1660 S COLUMBIAN WAY
Mailing Address - Street 2:VA PUGET SOUND HEALTH CARE SYSTEM (S-111-ONC)
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98108-1532
Mailing Address - Country:US
Mailing Address - Phone:206-667-7994
Mailing Address - Fax:206-667-5255
Practice Address - Street 1:1660 S COLUMBIAN WAY
Practice Address - Street 2:VA PUGET SOUND HEALTH CARE SYSTEM (S-111-ONC)
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98108-1532
Practice Address - Country:US
Practice Address - Phone:206-667-7994
Practice Address - Fax:206-667-5255
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00040300207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA247630Medicare UPIN