Healthcare Provider Details

I. General information

NPI: 1568457265
Provider Name (Legal Business Name): ROY N GRANTHAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 12/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4221 S WESTERN AVE 2010
OKLAHOMA CITY OK
73109-3447
US

IV. Provider business mailing address

3545 NW 58TH ST 450
OKLAHOMA CITY OK
73112-4726
US

V. Phone/Fax

Practice location:
  • Phone: 405-231-0540
  • Fax: 405-644-5309
Mailing address:
  • Phone: 405-951-4360
  • Fax: 866-857-2543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number16465
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: