Provider Demographics
NPI:1164471009
Name:LORD, JONATHAN GRANT (DO)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:GRANT
Last Name:LORD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 36TH AVENUE CT
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-2807
Mailing Address - Country:US
Mailing Address - Phone:970-330-1121
Mailing Address - Fax:970-515-6576
Practice Address - Street 1:1801 16TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-5154
Practice Address - Country:US
Practice Address - Phone:970-352-4121
Practice Address - Fax:970-515-6576
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO19999207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01199991Medicaid
COC402588Medicare ID - Type Unspecified
CO01199991Medicaid