Provider Demographics
NPI:1710092077
Name:GRANT, WALTER KASTLER III (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:KASTLER
Last Name:GRANT
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:WALTER
Other - Middle Name:
Other - Last Name:GRANT
Other - Suffix:III
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:JMM SUITE 2525
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-9528
Mailing Address - Fax:601-984-6439
Practice Address - Street 1:920 TOMMY MUNRO DR
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2150
Practice Address - Country:US
Practice Address - Phone:228-396-8101
Practice Address - Fax:601-496-8101
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL29157208000000X
MS14991208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00116939Medicaid
MS$$$$$$$$$HOtherBCBS
MS$$$$$$$$$GOtherBCBS
MS$$$$$$$$$EOtherBCBS
MS$$$$$$$$$IOtherBCBS
MS00116939Medicaid
MS$$$$$$$$$BOtherBCBS
MS00116939Medicaid
MS370000285Medicare ID - Type Unspecified
MS302I375964Medicare PIN
MS$$$$$$$$$EOtherBCBS