Provider Demographics
NPI:1003810888
Name:GRANT, WILSON WAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:WILSON
Middle Name:WAYNE
Last Name:GRANT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5282 MEDICAL DR
Mailing Address - Street 2:STE 310
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-6044
Mailing Address - Country:US
Mailing Address - Phone:210-614-8687
Mailing Address - Fax:210-614-7529
Practice Address - Street 1:5282 MEDICAL DR
Practice Address - Street 2:STE 310
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-6044
Practice Address - Country:US
Practice Address - Phone:210-614-8687
Practice Address - Fax:210-614-7529
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXD3243208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX853457OtherBLUE CROSS
TX853457Medicare ID - Type Unspecified
TXC16265Medicare UPIN