Basic Information
| Provider Information | |||||||||
| NPI: | 1982765582 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORT | ||||||||
| FirstName: | GRADY | ||||||||
| MiddleName: | REYNOLDS | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 116 W. MINNESOTA AVE | ||||||||
| Address2: | |||||||||
| City: | MCCLOUD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 96057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309642389 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1140 MAIN ST | ||||||||
| Address2: | LIVINGSTON MEDICAL GROUP | ||||||||
| City: | LIVINGSTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953341257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093947913 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 09/02/2017 | ||||||||
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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 | 208000000X | G27353 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.