Provider Demographics
NPI:1295878866
Name:GRANT, HEATHER (MD)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:
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 1:220 FORT SALONGA RD STE 301
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-3900
Mailing Address - Country:US
Mailing Address - Phone:631-486-7710
Mailing Address - Fax:631-410-1969
Practice Address - Street 1:220 FORT SALONGA RD STE 301
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-3900
Practice Address - Country:US
Practice Address - Phone:631-486-7710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210646207RG0300X, 207RH0002X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02238379Medicaid
NY02238379Medicaid
NYH55317Medicare UPIN