Individual
DR. BRADLEY P GRANT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1480 S WICKHAM RD, WEST MELBOURNE, FL 32904-2447
(321) 724-2188
(321) 724-2833
Mailing address
1480 S WICKHAM RD, WEST MELBOURNE, FL 32904-2447
(321) 724-2188
(321) 724-2833
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
ME80040
FL
207ND0101X
MOHS-Micrographic Surgery Physician
ME80040
FL
207NS0135X
Procedural Dermatology Physician
ME80040
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2120225050101
BEECH STREET
FL
05
—
261442100
—
FL
01
—
51915
BLUE SHIELD
FL
01
—
CIGNA
0560163
FL
Enumeration date
07/08/2005
Last updated
06/06/2008
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