Provider Demographics
NPI:1619953676
Name:GRANT-VERMONT, ANDREA JOY (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:JOY
Last Name:GRANT-VERMONT
Suffix:
Gender:F
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:PO BOX 734812
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-4812
Mailing Address - Country:US
Mailing Address - Phone:210-358-9500
Mailing Address - Fax:210-358-9183
Practice Address - Street 1:4647 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4403
Practice Address - Country:US
Practice Address - Phone:210-358-8144
Practice Address - Fax:210-358-8536
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN0060208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX201033201Medicaid
TX201033201Medicaid
TX8L10614Medicare PIN