Provider Demographics
NPI:1760485981
Name:GRANT, WILLIAM T (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:T
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 1:908 E JEFFERSON ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22902-5375
Mailing Address - Country:US
Mailing Address - Phone:434-817-7200
Mailing Address - Fax:434-817-7205
Practice Address - Street 1:908 E JEFFERSON ST
Practice Address - Street 2:SUITE 101
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22902-5375
Practice Address - Country:US
Practice Address - Phone:434-817-7200
Practice Address - Fax:434-817-7205
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101036663174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA3502513OtherCIGNA
VA146381OtherSOUTHERN HEALTH
VAH0672OtherRR MEDICARE - GRP NUMBER
VA284735OtherANTHEM
VA367116OtherMAMSI
VA6401082Medicaid
VA14105OtherOPTIMA HEALTH
VAH0672OtherRR MEDICARE - GRP NUMBER
VA284735OtherANTHEM
VA250000255Medicare PIN