MEDICARE: DR. LAURIE UPTON DE GRAND M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	0101250763	VA
2	207V00000X	Obstetrics & Gynecology Physician	0101250763	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	-002	OTHER	VA	TRICARE/CHAMPUS
2	448890	OTHER	VA	ANTHEM BC/BS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	PAR	OTHER	VA	VIRGINIA HEALTH NETWORK
5	1922204759	OTHER	VA	VIRGINIA PREMIER HEALTH PLAN
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	PAR	OTHER	VA	AETNA
8	1922204759	OTHER	VA	UNITED HEALTHCARE
9	PAR	OTHER	VA	CORVEL
10	10085658	OTHER	VA	OPTIMA HEALTH
11	PAR	OTHER	VA	CIGNA
12	PAR	OTHER	VA	MULTIPLAN
13	PAR	OTHER	VA	USA MANAGED CARE
14	1922204759	OTHER	VA	COVENTRY NATIONAL/SOUTHERN HEALTH SERVICES

General Provider Information

NPI Number	:	1922204759
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAURIE UPTON DE GRAND M.D.

Provider Business Mailing Address
First Line	:	828 HEALTHY WAY STE 330
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-7959
Country	:	US
Telephone Number	:	757-461-3890
Fax Number	:	757-467-0301

Provider Business Practice Location Address
First Line	:	828 HEALTHY WAY STE 330
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-7959
Country	:	US
Telephone Number	:	757-461-3890
Fax Number	:	757-467-0301

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2007
Last Update Date	:	06/01/2021

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