Provider Demographics
NPI:1235469644
Name:GRANT, GEORGE K (IDC)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:K
Last Name:GRANT
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 MICHELLE LN
Mailing Address - Street 2:APT 304
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-4278
Mailing Address - Country:US
Mailing Address - Phone:360-396-6789
Mailing Address - Fax:
Practice Address - Street 1:195 MICHELLE LN
Practice Address - Street 2:APT 304
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-4278
Practice Address - Country:US
Practice Address - Phone:360-396-6789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-06
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman