Provider Demographics
NPI:1588087803
Name:DAVIS, GRANT (MD)
Entity type:Individual
Prefix:MR
First Name:GRANT
Middle Name:
Last Name:DAVIS
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 1:2480 SONOMA ST
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-3027
Mailing Address - Country:US
Mailing Address - Phone:530-225-7800
Mailing Address - Fax:
Practice Address - Street 1:2480 SONOMA ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-3027
Practice Address - Country:US
Practice Address - Phone:540-459-7772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-22
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2251X0800X
390200000X
CAPTL16840207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06417Medicare UPIN