Provider Demographics
NPI:1982765582
Name:FORT, GRADY REYNOLDS (MD)
Entity Type:Individual
Prefix:DR
First Name:GRADY
Middle Name:REYNOLDS
Last Name:FORT
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 1:116 W. MINNESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:MCCLOUD
Mailing Address - State:CA
Mailing Address - Zip Code:96057
Mailing Address - Country:US
Mailing Address - Phone:530-964-2389
Mailing Address - Fax:
Practice Address - Street 1:1140 MAIN ST
Practice Address - Street 2:LIVINGSTON MEDICAL GROUP
Practice Address - City:LIVINGSTON
Practice Address - State:CA
Practice Address - Zip Code:95334-1257
Practice Address - Country:US
Practice Address - Phone:209-394-7913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2017-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27353208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA89449Medicare UPIN