Provider Demographics
NPI:1982925111
Name:GRADY L JETER M D INC
Entity Type:Organization
Organization Name:GRADY L JETER M D INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GRADY
Authorized Official - Middle Name:L
Authorized Official - Last Name:JETER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-559-4343
Mailing Address - Street 1:2430 SAMARITAN DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-3907
Mailing Address - Country:US
Mailing Address - Phone:408-559-4343
Mailing Address - Fax:408-371-6387
Practice Address - Street 1:2430 SAMARITAN DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-3907
Practice Address - Country:US
Practice Address - Phone:408-559-4343
Practice Address - Fax:408-371-6387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-22
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC30088207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADI882AMedicare UPIN
CAA34117Medicare UPIN