Provider Demographics
NPI:1639158462
Name:LABAN GRANT, OLGICA (MD)
Entity type:Individual
Prefix:DR
First Name:OLGICA
Middle Name:
Last Name:LABAN 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 1:690 N BROADWAY
Mailing Address - Street 2:SUITE GL1
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10603-2417
Mailing Address - Country:US
Mailing Address - Phone:914-428-3651
Mailing Address - Fax:914-428-2948
Practice Address - Street 1:333 WESTCHESTER AVE
Practice Address - Street 2:SUITE E104
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10604-2910
Practice Address - Country:US
Practice Address - Phone:914-428-9213
Practice Address - Fax:914-428-9282
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ240414M602084N0400X
NY22183212084N0600X
NJ25MA077675002084N0600X
CT0495062084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0045675Medicaid
NY02583333Medicaid
NY542N51Medicare ID - Type Unspecified
NY02583333Medicaid
NJ0045675Medicaid
NJ084213Medicare ID - Type Unspecified