Provider Demographics
NPI:1194115626
Name:GRANT, MATTHEW (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:GRANT
Suffix:
Gender:M
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:UNIT 33100
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09180-3100
Mailing Address - Country:US
Mailing Address - Phone:314-590-7632
Mailing Address - Fax:
Practice Address - Street 1:UNIT 33100
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09180-3100
Practice Address - Country:US
Practice Address - Phone:314-590-7632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-04
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NE294962085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program