Individual
DR. KIRK ANTHONY GRANTHAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
2530 BERT KOUNS LOOP, SUITE 138, SHREVEPORT, LA 71118-3132
(318) 588-4726
(318) 900-7828
Mailing address
PO BOX 1264, BENTON, LA 71006-1264
(318) 588-4726
(318) 900-7828
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
MD.205467
LA
207Q00000X
Family Medicine Physician
TRN 14355
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
193488001
AR MEDICAID
AR
05
—
2303732
—
LA
Enumeration date
09/01/2009
Last updated
06/08/2021
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