Provider Demographics
NPI:1538596614
Name:GRAJEDA, MICHAEL DANIEL (DPT)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DANIEL
Last Name:GRAJEDA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N PARK ST STE B
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-3340
Mailing Address - Country:US
Mailing Address - Phone:970-516-1600
Mailing Address - Fax:970-459-3048
Practice Address - Street 1:111 N PARK ST STE B
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321
Practice Address - Country:US
Practice Address - Phone:970-516-1600
Practice Address - Fax:970-459-3048
Is Sole Proprietor?:No
Enumeration Date:2013-10-03
Last Update Date:2018-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT86634902401225100000X
TX1235743225100000X
CO0012733225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO58770330Medicaid
362965ZHVJMedicare UPIN