Individual
JOHNATHAN R GRANT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
520 S 7TH ST, VINCENNES, IN 47591
(812) 885-3243
(812) 885-3915
Mailing address
520 S 7TH ST, VINCENNES, IN 47591-1038
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
02004177A
IN
207R00000X
Internal Medicine Physician
5101017295
MI
207RC0200X
Critical Care Medicine (Internal Medicine) Physician
02004177A
IN
207RP1001X
Pulmonary Disease Physician
Primary
02004177A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000820667
ANTHEM
IN
05
—
201152480
—
IN
01
—
258190112
MEDICARE
IN
Enumeration date
08/19/2005
Last updated
01/11/2019
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