Provider Demographics
NPI:1639236797
Name:DISICK, GRANT I (MD)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:I
Last Name:DISICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS DEPT.
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:9970 CENTRAL PARK BLVD N
Practice Address - Street 2:SUITE 207
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428-2231
Practice Address - Country:US
Practice Address - Phone:561-487-5506
Practice Address - Fax:561-487-9261
Is Sole Proprietor?:No
Enumeration Date:2007-01-01
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME101748208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP998495OtherFREEDOM
FLP939616OtherOPTIMUM
FL11999OtherDIMENSION
FL58335OtherBCBS
FL973866OtherWELLCARE
FL9010497OtherCIGNA
FL1069247OtherCAREPLUS
FL7583920OtherAETNA
FL319558OtherAVMED
FL58335OtherBLUE CROSS OF FL
FL319558OtherAVMED
FLP998495OtherFREEDOM
FL7583920OtherAETNA