Provider Demographics
NPI:1023241403
Name:GRANTHAM, KIRK ANTHONY (MD)
Entity type:Individual
Prefix:DR
First Name:KIRK
Middle Name:ANTHONY
Last Name:GRANTHAM
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 1264
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:LA
Mailing Address - Zip Code:71006-1264
Mailing Address - Country:US
Mailing Address - Phone:318-588-4726
Mailing Address - Fax:318-900-7828
Practice Address - Street 1:2530 BERT KOUNS LOOP
Practice Address - Street 2:SUITE 138
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3132
Practice Address - Country:US
Practice Address - Phone:318-588-4726
Practice Address - Fax:318-900-7828
Is Sole Proprietor?:No
Enumeration Date:2009-09-01
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN 14355207Q00000X
LAMD.205467207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR193488001OtherAR MEDICAID
LA2303732Medicaid
4R186Medicare PIN