Provider Demographics
NPI:1972547297
Name:GRANT, SOPHIA Z (MD)
Entity Type:Individual
Prefix:DR
First Name:SOPHIA
Middle Name:Z
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 1:20 FELICITY LN
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-6101
Mailing Address - Country:US
Mailing Address - Phone:860-689-0026
Mailing Address - Fax:
Practice Address - Street 1:20 FELICITY LN
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-6101
Practice Address - Country:US
Practice Address - Phone:860-489-4144
Practice Address - Fax:860-489-4412
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0394342080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001394345Medicaid
CT001394345Medicaid
CT370001459Medicare ID - Type Unspecified