Individual
GRANT I DISICK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
9970 CENTRAL PARK BLVD N, SUITE 207, BOCA RATON, FL 33428-2231
(561) 487-5506
(561) 487-9261
Mailing address
2234 COLONIAL BLVD, ATTN: PAYER CONTRACTING & RELATIONS DEPT., FORT MYERS, FL 33907-1412
(239) 931-7342
(239) 931-7385
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
Primary
ME101748
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1069247
CAREPLUS
FL
01
—
11999
DIMENSION
FL
01
—
319558
AVMED
FL
01
—
58335
BCBS
FL
01
—
7583920
AETNA
FL
01
—
9010497
CIGNA
FL
01
—
973866
WELLCARE
FL
01
—
P939616
OPTIMUM
FL
01
—
P998495
FREEDOM
FL
Enumeration date
01/01/2007
Last updated
03/16/2017
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