Healthcare Provider Details

I. General information

NPI: 1871118208
Provider Name (Legal Business Name): JESSE GRANT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 N ROCKWELL AVE
BETHANY OK
73008-5246
US

IV. Provider business mailing address

2701 N ROCKWELL AVE
BETHANY OK
73008-5246
US

V. Phone/Fax

Practice location:
  • Phone: 405-789-4150
  • Fax: 405-789-1067
Mailing address:
  • Phone: 405-789-4150
  • Fax: 405-789-1067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35971
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: