Basic Information
| Provider Information | |||||||||
| NPI: | 1750806865 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRANT N KO MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1770 | ||||||||
| Address2: | |||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919441770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078007700 | ||||||||
| FaxNumber: | 7078007799 | ||||||||
| Practice Location | |||||||||
| Address1: | 1287 FULTON RD | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954014923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078007700 | ||||||||
| FaxNumber: | 7078007799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2017 | ||||||||
| LastUpdateDate: | 08/09/2017 | ||||||||
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| AuthorizedOfficialLastName: | KO | ||||||||
| AuthorizedOfficialFirstName: | GRANT | ||||||||
| AuthorizedOfficialMiddleName: | NORMAN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7078007700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | G49179 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.