Provider Demographics
NPI:1952754111
Name:LIGHTFOOT, GRANT (MD)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:LIGHTFOOT
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 1:2620 E BARNETT RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8344
Mailing Address - Country:US
Mailing Address - Phone:313-693-3363
Mailing Address - Fax:
Practice Address - Street 1:500 SW RAMSEY AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527
Practice Address - Country:US
Practice Address - Phone:541-472-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-22
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301110711390200000X
ORMD190290207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty