Provider Demographics
NPI:1366527079
Name:GRANTHAM, RICHARD L (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:GRANTHAM
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 1:139 WATERLOO ST SW
Mailing Address - Street 2:PO BOX 2171
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29801-3771
Mailing Address - Country:US
Mailing Address - Phone:803-642-1000
Mailing Address - Fax:803-642-0036
Practice Address - Street 1:139 WATERLOO ST SW
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-3756
Practice Address - Country:US
Practice Address - Phone:803-642-1000
Practice Address - Fax:803-642-0036
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16513207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1593Medicaid
SCB06973Medicare UPIN
SC4924650001Medicare NSC