Provider Demographics
NPI:1477973972
Name:GRANT, JEREMY (MD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:GRANT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20486 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:ONANCOCK
Mailing Address - State:VA
Mailing Address - Zip Code:23417
Mailing Address - Country:US
Mailing Address - Phone:757-302-2700
Mailing Address - Fax:757-787-9262
Practice Address - Street 1:20486 MARKET STREET
Practice Address - Street 2:
Practice Address - City:ONANCOCK
Practice Address - State:VA
Practice Address - Zip Code:23417
Practice Address - Country:US
Practice Address - Phone:757-302-2700
Practice Address - Fax:757-787-9262
Is Sole Proprietor?:No
Enumeration Date:2014-04-23
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA080208207V00000X
390200000X
VA0101267624207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program