Provider Demographics
NPI:1760584510
Name:JETER, GRADY LYNN (MD)
Entity Type:Individual
Prefix:
First Name:GRADY
Middle Name:LYNN
Last Name:JETER
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 1:2430 SAMARITAN DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-3907
Mailing Address - Country:US
Mailing Address - Phone:408-559-4343
Mailing Address - Fax:408-371-6387
Practice Address - Street 1:2430 SAMARITAN DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-3907
Practice Address - Country:US
Practice Address - Phone:408-559-4343
Practice Address - Fax:408-371-6387
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC30088174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA34117Medicare UPIN
CADI883ZMedicare UPIN