Healthcare Provider Details

I. General information

NPI: 1861738189
Provider Name (Legal Business Name): JONATHAN DOUGLAS GRANT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2012
Last Update Date: 01/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5121 S COTTONWOOD ST
MURRAY UT
84107-5701
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-3888
  • Fax: 801-442-3263
Mailing address:
  • Phone: 801-507-3888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberAU3354177
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number2015-00676
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number38030
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number10124565-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: