Healthcare Provider Details

I. General information

NPI: 1730757907
Provider Name (Legal Business Name): GRAYSON NATHANIEL MYNATT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2021
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4025 N SHERIDAN RD
CHICAGO IL
60613-2010
US

IV. Provider business mailing address

4025 N SHERIDAN RD
CHICAGO IL
60613-2010
US

V. Phone/Fax

Practice location:
  • Phone: 773-388-1600
  • Fax:
Mailing address:
  • Phone: 773-388-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2024031283
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036176984
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: