Healthcare Provider Details

I. General information

NPI: 1134784796
Provider Name (Legal Business Name): MARISSA C. GRANT DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 W 10TH AVE
COLUMBUS OH
43210-1240
US

IV. Provider business mailing address

4881 SUGAR MAPLE DR
WPAFB OH
45433-5529
US

V. Phone/Fax

Practice location:
  • Phone: 614-293-8487
  • Fax: 614-293-8153
Mailing address:
  • Phone: 937-257-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number34.016761.MIL
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0102206367
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: