Provider Demographics
NPI:1053427013
Name:J. GARY GRANT, MD, INC.
Entity type:Organization
Organization Name:J. GARY GRANT, MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:831-373-2322
Mailing Address - Street 1:830 BAYVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:PACIFIC GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:93950-2511
Mailing Address - Country:US
Mailing Address - Phone:831-373-2322
Mailing Address - Fax:
Practice Address - Street 1:830 BAYVIEW AVE
Practice Address - Street 2:
Practice Address - City:PACIFIC GROVE
Practice Address - State:CA
Practice Address - Zip Code:93950-2511
Practice Address - Country:US
Practice Address - Phone:831-373-2322
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG83783207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G387830Medicaid
A47599Medicare UPIN
CA00G387830Medicare ID - Type Unspecified