Basic Information
| Provider Information | |||||||||
| NPI: | 1174940027 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRADY | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PSC 455 BOX 208 | ||||||||
| Address2: | |||||||||
| City: | FPO | ||||||||
| State: | AP | ||||||||
| PostalCode: | 965400003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7579537550 | ||||||||
| FaxNumber: | 7579537560 | ||||||||
| Practice Location | |||||||||
| Address1: | USNH GUAM | ||||||||
| Address2: | BLDG #50 FARENHOLT AVE | ||||||||
| City: | AGANA HEIGHTS | ||||||||
| State: | GU | ||||||||
| PostalCode: | 96910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6713449340 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2014 | ||||||||
| LastUpdateDate: | 06/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 0116027479 | VA | N | Allopathic & Osteopathic Physicians | General Practice | 2085R0202X | 0101258688 | VA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.