Provider Demographics
NPI:1780895755
Name:GRINER, DEVAN (MD)
Entity type:Individual
Prefix:DR
First Name:DEVAN
Middle Name:
Last Name:GRINER
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11762 S STATE ST STE 110
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-7158
Mailing Address - Country:US
Mailing Address - Phone:385-218-0587
Mailing Address - Fax:385-381-4447
Practice Address - Street 1:11762 S STATE ST STE 110
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-7158
Practice Address - Country:US
Practice Address - Phone:385-218-0587
Practice Address - Fax:385-381-4447
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT374716-12052086S0122X, 208200000X, 2082S0099X
TN485852086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
103I933353OtherMEDICARE PTAN