Provider Demographics
NPI:1366543902
Name:HOLDER, GRADY MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:GRADY
Middle Name:MICHAEL
Last Name:HOLDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:MICHAEL
Other - Middle Name:
Other - Last Name:HOLDER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3701 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113-3611
Mailing Address - Country:US
Mailing Address - Phone:303-360-6276
Mailing Address - Fax:303-467-5355
Practice Address - Street 1:11005 RALSTON RD
Practice Address - Street 2:SUITE 100G
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80004-4551
Practice Address - Country:US
Practice Address - Phone:303-431-0844
Practice Address - Fax:303-456-6124
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0028219207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01282193Medicaid
CO10354697OtherCAQH
CO10354697OtherCAQH
COBH2816671OtherDEA
CO01282193Medicaid