Healthcare Provider Details

I. General information

NPI: 1629036413
Provider Name (Legal Business Name): JAMES J GRADY JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 11/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 W LODI AVE
LODI CA
95242-3000
US

IV. Provider business mailing address

PO BOX 255228
SACRAMENTO CA
95865-5228
US

V. Phone/Fax

Practice location:
  • Phone: 209-366-1990
  • Fax: 209-366-2169
Mailing address:
  • Phone: 855-771-0335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA26041
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: