Provider Demographics
NPI:1699777557
Name:GRANT, M GRETCHEN (MD)
Entity type:Individual
Prefix:DR
First Name:M
Middle Name:GRETCHEN
Last Name:GRANT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:950 ROUTE 146 STE 2
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-3667
Mailing Address - Country:US
Mailing Address - Phone:518-371-3391
Mailing Address - Fax:518-371-1626
Practice Address - Street 1:950 ROUTE 146 STE 2
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-3667
Practice Address - Country:US
Practice Address - Phone:185-371-3391
Practice Address - Fax:518-371-1626
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY142726207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B82596Medicare UPIN
NY39889BMedicare PIN