Provider Demographics
NPI:1669500096
Name:GRANT, JEFFREY S (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:S
Last Name:GRANT
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:PO BOX 677
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499-0677
Mailing Address - Country:US
Mailing Address - Phone:505-325-0072
Mailing Address - Fax:505-327-1739
Practice Address - Street 1:608 E COMANCHE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6815
Practice Address - Country:US
Practice Address - Phone:505-325-0072
Practice Address - Fax:505-327-1739
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM99216208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM99216OtherSTATE LICENSE NUMBER
NM99216OtherSTATE LICENSE NUMBER