Provider Demographics
NPI:1841211695
Name:GRANT, L V (DPM)
Entity Type:Individual
Prefix:DR
First Name:L
Middle Name:V
Last Name:GRANT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 29TH ST
Mailing Address - Street 2:STE 202
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3581
Mailing Address - Country:US
Mailing Address - Phone:510-272-9588
Mailing Address - Fax:510-272-9693
Practice Address - Street 1:401 29TH ST
Practice Address - Street 2:STE 202
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3581
Practice Address - Country:US
Practice Address - Phone:510-272-9588
Practice Address - Fax:510-272-9693
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE14530213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE145230Medicaid
T10963Medicare UPIN
CAE145230Medicaid