Provider Demographics
NPI:1154345346
Name:GRANT, DORRETTE PATRICE (MD)
Entity type:Individual
Prefix:
First Name:DORRETTE
Middle Name:PATRICE
Last Name:GRANT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1689
Mailing Address - Street 2:
Mailing Address - City:ETOWAH
Mailing Address - State:NC
Mailing Address - Zip Code:28729-1689
Mailing Address - Country:US
Mailing Address - Phone:910-488-7548
Mailing Address - Fax:866-376-8277
Practice Address - Street 1:2573 RAVENHILL DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5451
Practice Address - Country:US
Practice Address - Phone:910-488-7548
Practice Address - Fax:866-376-8277
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111115207V00000X
NC2000D0063207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5909310Medicaid
NC5909310Medicaid
NC2281270DMedicare PIN