Healthcare Provider Details

I. General information

NPI: 1124078340
Provider Name (Legal Business Name): JEREMY D GRADON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 12/30/2019
Certification Date: 12/30/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2435 W BELVEDERE AVE SUITE 17
BALTIMORE MD
21215-5224
US

IV. Provider business mailing address

2401 W BELVEDERE AVE ATTN: CREDENTIALING
BALTIMORE MD
21215-5216
US

V. Phone/Fax

Practice location:
  • Phone: 410-601-5941
  • Fax: 410-601-6006
Mailing address:
  • Phone: 410-601-5524
  • Fax: 410-601-8946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD42061
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberD42061
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: