Provider Demographics
NPI:1841395357
Name:GRANT, GWENDOLYN (MD)
Entity Type:Individual
Prefix:DR
First Name:GWENDOLYN
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 THREE SPRINGS BLVD STE 275
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-8296
Mailing Address - Country:US
Mailing Address - Phone:970-764-3740
Mailing Address - Fax:970-764-3643
Practice Address - Street 1:1010 THREE SPRINGS BLVD STE 275
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-8296
Practice Address - Country:US
Practice Address - Phone:970-764-3740
Practice Address - Fax:970-764-3643
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0044790207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO85030872Medicaid
NMR4911Medicaid
AZ428822Medicaid
NMR4911Medicaid
AZ428822Medicaid
COC806437Medicare PIN
8HF465Medicare PIN