Provider Demographics
NPI:1972590453
Name:MAULDIN, GRANT K (MD)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:K
Last Name:MAULDIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 108835
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73101-8835
Mailing Address - Country:US
Mailing Address - Phone:405-755-9350
Mailing Address - Fax:405-775-9360
Practice Address - Street 1:3048 SW 89TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-6385
Practice Address - Country:US
Practice Address - Phone:405-755-9350
Practice Address - Fax:405-775-9360
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2013-07-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK13115207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK4351614OtherAETNA
OK141657700OtherDEPT OF LABOR
OK080027069OtherRAILROAD MEDICARE
OK100111630AMedicaid
OK080027069OtherRAILROAD MEDICARE
OKD34998Medicare UPIN
OK080027069OtherRAILROAD MEDICARE