Provider Demographics
NPI:1063075224
Name:CARLISLE, GRANT ROBERT
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:ROBERT
Last Name:CARLISLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55415-1623
Mailing Address - Country:US
Mailing Address - Phone:612-873-3000
Mailing Address - Fax:
Practice Address - Street 1:1542 GOLF COURSE RD STE 201
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3537
Practice Address - Country:US
Practice Address - Phone:218-326-3433
Practice Address - Fax:218-326-3435
Is Sole Proprietor?:No
Enumeration Date:2019-04-15
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD481576207W00000X
MN76307207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology