Provider Demographics
NPI:1356359624
Name:CETTIE, GRANT EVAN (DPM)
Entity type:Individual
Prefix:DR
First Name:GRANT
Middle Name:EVAN
Last Name:CETTIE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2921 SOUTHWEST PKWY
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-4121
Mailing Address - Country:US
Mailing Address - Phone:940-692-7078
Mailing Address - Fax:940-692-7079
Practice Address - Street 1:2921 SOUTHWEST PKWY
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-4121
Practice Address - Country:US
Practice Address - Phone:940-692-7078
Practice Address - Fax:940-692-7079
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1092213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8B5600OtherBCBS
TX1536252-01Medicaid
TX8479NOMedicare PIN
TX8B5600OtherBCBS