Healthcare Provider Details

I. General information

NPI: 1982925111
Provider Name (Legal Business Name): GRADY L JETER M D INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2010
Last Update Date: 11/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2430 SAMARITAN DR
SAN JOSE CA
95124-3907
US

IV. Provider business mailing address

2430 SAMARITAN DR
SAN JOSE CA
95124-3907
US

V. Phone/Fax

Practice location:
  • Phone: 408-559-4343
  • Fax: 408-371-6387
Mailing address:
  • Phone: 408-559-4343
  • Fax: 408-371-6387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberC30088
License Number StateCA

VIII. Authorized Official

Name: GRADY L JETER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 408-559-4343