Provider Demographics
NPI:1962497677
Name:GRANT, GARRY D (MD)
Entity type:Individual
Prefix:DR
First Name:GARRY
Middle Name:D
Last Name:GRANT
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 2450
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MT
Mailing Address - Zip Code:59917-2450
Mailing Address - Country:US
Mailing Address - Phone:812-204-1703
Mailing Address - Fax:
Practice Address - Street 1:2055 MUD CREEK RD
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:MT
Practice Address - Zip Code:59917-9070
Practice Address - Country:US
Practice Address - Phone:812-424-2020
Practice Address - Fax:812-424-3000
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-19
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PHYS-LIC-57501207WX0107X
AZ21735207W00000X
IL036117029207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000042320OtherANTHEM
KY64878010Medicaid
IN200000980Medicaid
259157OtherHEALTHLINK
4500741OtherAETNA
IN200000980Medicaid
000000042320OtherANTHEM
F79625Medicare UPIN