Provider Demographics
NPI:1063465235
Name:GRANT, EDWARD GARY (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:GARY
Last Name:GRANT
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 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-8541
Mailing Address - Fax:323-442-8755
Practice Address - Street 1:1500 SAN PABLO ST FL 2
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5313
Practice Address - Country:US
Practice Address - Phone:323-442-8541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG619102085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG61910HMedicare PIN
CAWG61910DMedicare PIN
CAE84942Medicare UPIN
CAWG61910FMedicare PIN
CAWG61910EMedicare PIN
CAWG61910CMedicare PIN
CA00G619100G56OtherCAL-OPTIMA
CAWG61910EMedicare PIN
CAWG61910CMedicare PIN