Healthcare Provider Details

I. General information

NPI: 1245793728
Provider Name (Legal Business Name): GRANT JEFFREY RANDALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 07/26/2026
Certification Date: 07/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 WATERLINE ST
CHARLESTON SC
29492-9049
US

IV. Provider business mailing address

135 RUTLEDGE AVENUE MSC 578
CHARLESTON SC
29425
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-3021
  • Fax:
Mailing address:
  • Phone: 843-792-1414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2024001206
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: