Basic Information
| Provider Information | |||||||||
| NPI: | 1700945342 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRANT | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | PROF. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 UNIVERSITY BLVD | ||||||||
| Address2: | JOHN SEALY ANNEX 5.112 | ||||||||
| City: | GALVESTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775550561 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097722436 | ||||||||
| FaxNumber: | 4097722035 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 UNIVERSITY BLVD | ||||||||
| Address2: | JOHN SEALY ANNEX 5.112 | ||||||||
| City: | GALVESTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775550561 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097722436 | ||||||||
| FaxNumber: | 4097729532 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 01/09/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0201X | 49177 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine | Allergy & Immunology | 207RA0201X | E1324 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Allergy & Immunology | 207KI0005X | E1324 | TX | N | Allopathic & Osteopathic Physicians | Allergy & Immunology | Clinical & Laboratory Immunology |
ID Information
| ID | Type | State | Issuer | Description | 117162102 | 05 | TX | MEDICAID | 67226051 | 05 | CO | MEDICAID |