Provider Demographics
NPI:1396745659
Name:GRANDT, VICTOR KIMBALL (DPM)
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:KIMBALL
Last Name:GRANDT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4946 W MINERAL KING
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291
Mailing Address - Country:US
Mailing Address - Phone:559-624-1405
Mailing Address - Fax:559-624-1746
Practice Address - Street 1:4946 W MINERAL KING
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291
Practice Address - Country:US
Practice Address - Phone:559-624-1405
Practice Address - Fax:559-624-1746
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005143213E00000X
CAE4724213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACT4542Medicare PIN