Provider Demographics
NPI:1164424560
Name:GRANDIS, STUART VICTOR (MD)
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:VICTOR
Last Name:GRANDIS
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 1:1 GAYMONT RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23229-8014
Mailing Address - Country:US
Mailing Address - Phone:804-288-8976
Mailing Address - Fax:804-288-8976
Practice Address - Street 1:1 GAYMONT RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-8014
Practice Address - Country:US
Practice Address - Phone:804-288-8976
Practice Address - Fax:804-288-8976
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101018603207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5618673Medicaid
VA5618673Medicaid