Basic Information
| Provider Information | |||||||||
| NPI: | 1568457265 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRANTHAM | ||||||||
| FirstName: | ROY | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3545 NW 58TH ST | ||||||||
| Address2: | 450 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731124726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059514360 | ||||||||
| FaxNumber: | 8668572543 | ||||||||
| Practice Location | |||||||||
| Address1: | 4221 S WESTERN AVE | ||||||||
| Address2: | 2010 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731093447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052310540 | ||||||||
| FaxNumber: | 4056445309 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2005 | ||||||||
| LastUpdateDate: | 12/04/2014 | ||||||||
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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 | 2086S0129X | 16465 | OK | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 5765290 | 01 | OK | AETNA | OTHER | 060052653 | 01 | RAILROAD MEDICARE | OTHER | 100122170A | 05 | OK | MEDICAID | 125309100 | 01 | OK | DOL | OTHER |