Healthcare Provider Details

I. General information

NPI: 1255345286
Provider Name (Legal Business Name): CHARLES C GRANT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4806 N ORANGE BLOSSOM TRL
ORLANDO FL
32810-1605
US

IV. Provider business mailing address

1109 SW 10TH ST
OCALA FL
34474-2725
US

V. Phone/Fax

Practice location:
  • Phone: 407-206-3326
  • Fax:
Mailing address:
  • Phone: 352-629-3433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberME12612
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: