Healthcare Provider Details

I. General information

NPI: 1477016921
Provider Name (Legal Business Name): MARK AUSTIN GRANT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2019
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 E AJO WAY
TUCSON AZ
85713-6204
US

IV. Provider business mailing address

3950 S COUNTRY CLUB RD STE 130
TUCSON AZ
85714-2203
US

V. Phone/Fax

Practice location:
  • Phone: 520-874-4082
  • Fax:
Mailing address:
  • Phone: 520-874-4800
  • Fax: 520-874-4801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR77275
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: