Provider Demographics
NPI:1841215613
Name:GRANT, SOPHIA R (MD)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:R
Last Name:GRANT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26520 CACTUS AVE
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-3927
Mailing Address - Country:US
Mailing Address - Phone:951-486-4345
Mailing Address - Fax:951-486-4330
Practice Address - Street 1:26520 CACTUS AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-3927
Practice Address - Country:US
Practice Address - Phone:951-486-4345
Practice Address - Fax:951-486-4330
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66209207P00000X, 2080C0008X, 208000000X
TXN6326207PP0204X
OK24883208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No2080C0008XAllopathic & Osteopathic PhysiciansPediatricsChild Abuse Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200089650AMedicaid
TX213341503Medicaid
TX213341504OtherCSHCN
OK200089650AMedicaid