Provider Demographics
NPI:1316188311
Name:GRANT, LORI A (DPM)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:A
Last Name:GRANT
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:LORI
Other - Middle Name:S
Other - Last Name:ADDISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:719 RODEL CV STE 2001
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5716
Mailing Address - Country:US
Mailing Address - Phone:407-878-4720
Mailing Address - Fax:407-878-4732
Practice Address - Street 1:719 RODEL CV STE 2001
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-5716
Practice Address - Country:US
Practice Address - Phone:407-878-4720
Practice Address - Fax:407-878-4732
Is Sole Proprietor?:No
Enumeration Date:2009-03-20
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3334213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001457300Medicaid
FL6500SOtherBLUE CROSS BLUE SHIELD
5437720008Medicare NSC
FL001457300Medicaid
5437720003Medicare NSC