Provider Demographics
NPI:1174151369
Name:BREELAND, GRANT (MD)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:BREELAND
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:PO BOX 3488 DEPT 05-048
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803-3488
Mailing Address - Country:US
Mailing Address - Phone:866-264-3435
Mailing Address - Fax:706-596-6704
Practice Address - Street 1:815 S PINE ST
Practice Address - Street 2:
Practice Address - City:VIVIAN
Practice Address - State:LA
Practice Address - Zip Code:71082-3353
Practice Address - Country:US
Practice Address - Phone:318-375-3235
Practice Address - Fax:706-596-6704
Is Sole Proprietor?:No
Enumeration Date:2020-04-01
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
TXU6923207R00000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine