Provider Demographics
NPI:1073638680
Name:GRANT, COLETTE L (MD)
Entity Type:Individual
Prefix:
First Name:COLETTE
Middle Name:L
Last Name:GRANT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:COLETTE
Other - Middle Name:L
Other - Last Name:GRANT-BURKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:32577 CAMINITO ROSADA
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-1262
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3860 CALLE FORTUNADA
Practice Address - Street 2:STE 200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4800
Practice Address - Country:US
Practice Address - Phone:858-636-4300
Practice Address - Fax:858-636-4319
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG65865208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics