Provider Demographics
NPI:1710238100
Name:GRANT, THOMAS ARCHIE (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ARCHIE
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 1:9392 STONEBRIAR CIR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-3728
Mailing Address - Country:US
Mailing Address - Phone:318-795-0406
Mailing Address - Fax:
Practice Address - Street 1:9392 STONEBRIAR CIR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-3728
Practice Address - Country:US
Practice Address - Phone:318-795-0406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA092262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology