Healthcare Provider Details

I. General information

NPI: 1497772412
Provider Name (Legal Business Name): STEWART A GRANT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 11/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 KINGSWAY RD SUITE A
BRANDON FL
33510-4679
US

IV. Provider business mailing address

16765 FISHHAWK BLVD 314
LITHIA FL
33547-3860
US

V. Phone/Fax

Practice location:
  • Phone: 813-655-5106
  • Fax: 813-655-4460
Mailing address:
  • Phone: 813-655-5106
  • Fax: 813-655-4460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME72163
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: