Provider Demographics
NPI:1912064577
Name:GRANT, JONATHAN R (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:R
Last Name:GRANT
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 1:111 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4105
Mailing Address - Country:US
Mailing Address - Phone:360-336-2178
Mailing Address - Fax:360-336-1674
Practice Address - Street 1:111 S 13TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4105
Practice Address - Country:US
Practice Address - Phone:360-336-2178
Practice Address - Fax:360-336-1674
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47898-020207Y00000X
MA242010207Y00000X
WAMD60187241207YX0905X, 2082S0099X, 208600000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0271141OtherLABOR AND INDUSTRIES
WA2009841Medicaid
P00700778OtherRAILROAD MEDICARE
WA0271141OtherLABOR AND INDUSTRIES