Provider Demographics
NPI:1851570006
Name:GRANT-SPENCER, TELITHA K (MD)
Entity Type:Individual
Prefix:MS
First Name:TELITHA
Middle Name:K
Last Name:GRANT-SPENCER
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:PO BOX 150
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:MS
Mailing Address - Zip Code:39359-0150
Mailing Address - Country:US
Mailing Address - Phone:601-625-7403
Mailing Address - Fax:601-625-7404
Practice Address - Street 1:1488 HWY 487
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:MS
Practice Address - Zip Code:39359-0150
Practice Address - Country:US
Practice Address - Phone:601-625-7403
Practice Address - Fax:601-625-7404
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-24
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.200333207R00000X, 208000000X
MS24502207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00656244Medicaid
LA1069973Medicaid