Provider Demographics
NPI:1407979032
Name:GRANT, STEFAN CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:STEFAN
Middle Name:CHARLES
Last Name:GRANT
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 1:1430 TULANE AVE # 8016
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-2632
Mailing Address - Country:US
Mailing Address - Phone:504-988-7518
Mailing Address - Fax:504-988-8252
Practice Address - Street 1:1430 TULANE AVE # 8016
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-2632
Practice Address - Country:US
Practice Address - Phone:504-988-7518
Practice Address - Fax:504-988-8252
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014-02170207RH0003X
AL30801207RH0003X
LA335796207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051116824OtherBCBS
AL051116827OtherBCBS
AL128723Medicaid
AL128725Medicaid
AL051116826OtherBCBS
MS09003745Medicaid
AL051116825OtherBCBS
AL128724Medicaid
AL128760Medicaid
AL128725Medicaid
MS09003745Medicaid