Healthcare Provider Details

I. General information

NPI: 1184310203
Provider Name (Legal Business Name): KEITH WOODWARD GRAMLING JR. DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2023
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MAGNOLIA CT
MOULTRIE GA
31768-6764
US

IV. Provider business mailing address

1 MAGNOLIA CT
MOULTRIE GA
31768-6764
US

V. Phone/Fax

Practice location:
  • Phone: 229-502-9753
  • Fax:
Mailing address:
  • Phone: 229-502-9753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number105429
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: