Provider Demographics
NPI:1215951371
Name:GRADY, IAN P (MD)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:P
Last Name:GRADY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 BUENAVENTURA BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-0160
Mailing Address - Country:US
Mailing Address - Phone:530-243-5551
Mailing Address - Fax:530-245-0572
Practice Address - Street 1:1335 BUENAVENTURA BLVD STE 204
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0160
Practice Address - Country:US
Practice Address - Phone:530-243-5551
Practice Address - Fax:530-245-0572
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73597208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G735970Medicaid
CA00G735970Medicaid
CA00G735970Medicare PIN
CAS19572Medicare UPIN