Basic Information
| Provider Information | |||||||||
| NPI: | 1134184476 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAYSON | ||||||||
| FirstName: | JERROLD | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3222 | ||||||||
| Address2: | |||||||||
| City: | NAPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945580293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072617821 | ||||||||
| FaxNumber: | 7072563508 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 SANITARIUM RD | ||||||||
| Address2: | |||||||||
| City: | DEER PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945769714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7079636430 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | G26478 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00G264780 | 05 | CA | MEDICAID |