Healthcare Provider Details

I. General information

NPI: 1720666795
Provider Name (Legal Business Name): GRANT ELLIOT MACKINNON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7950 W JEFFERSON BLVD
FORT WAYNE IN
46804-4160
US

IV. Provider business mailing address

7221 ENGLE RD STE 220
FORT WAYNE IN
46804-2233
US

V. Phone/Fax

Practice location:
  • Phone: 260-435-7001
  • Fax:
Mailing address:
  • Phone: 260-702-8229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301509433
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: