Provider Demographics
NPI:1073597092
Name:GRANT, VINCENT L (MD PLC)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:L
Last Name:GRANT
Suffix:
Gender:M
Credentials:MD PLC
Other - Prefix:
Other - First Name:VINCENT
Other - Middle Name:L
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD FACS
Mailing Address - Street 1:PO BOX 1007
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-1007
Mailing Address - Country:US
Mailing Address - Phone:601-766-0308
Mailing Address - Fax:601-766-0309
Practice Address - Street 1:57 DEWEY ST
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452-5707
Practice Address - Country:US
Practice Address - Phone:601-766-0308
Practice Address - Fax:601-766-0309
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-02
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME488042086S0129X
MS16759208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00122104Medicaid