Provider Demographics
NPI:1386611705
Name:HERTEL, GRANT A (MD)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:A
Last Name:HERTEL
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:PO BOX 42210
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85080-2210
Mailing Address - Country:US
Mailing Address - Phone:623-889-7403
Mailing Address - Fax:623-889-7407
Practice Address - Street 1:1255 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-1210
Practice Address - Country:US
Practice Address - Phone:602-685-5211
Practice Address - Fax:602-685-5028
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7621207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E34937Medicare UPIN
AZZ64655Medicare PIN