Basic Information
| Provider Information | |||||||||
| NPI: | 1134373665 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRANTZ | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | RYAN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 N 1900 E # 3R210 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841320002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015856387 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 30 N 1900 E # 3R210 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841320002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015856387 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2008 | ||||||||
| LastUpdateDate: | 12/12/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | UT | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084N0400X | 7151935-8905 | UT | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084V0102X | 7151935-8905 | UT | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Vascular Neurology |
No ID Information.