Provider Demographics
NPI:1932140456
Name:GRANTHAM, DALE COURTNEY (MD)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:COURTNEY
Last Name:GRANTHAM
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 1:3129 N 109TH TER
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66109-8901
Mailing Address - Country:US
Mailing Address - Phone:509-942-4793
Mailing Address - Fax:
Practice Address - Street 1:1110 BLUE SAGE RD NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-5763
Practice Address - Country:US
Practice Address - Phone:509-942-4793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041473207P00000X
NMMD2012-0049193207P00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8317067Medicaid
WA3075GROtherBSWA
WA605960008OtherDEEOIC
WA0202687OtherLIWA
WA3075GROtherBSWA
WAP00296171Medicare PIN