Provider Demographics
NPI:1487696514
Name:GRAND, MARK ALAN (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:GRAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:55 WATER ST
Mailing Address - Street 2:12TH FLOOR - CREDENTIALING
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10041-0004
Mailing Address - Country:US
Mailing Address - Phone:646-680-2888
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:447 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-1702
Practice Address - Country:US
Practice Address - Phone:718-858-6300
Practice Address - Fax:718-858-0145
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1539331207R00000X
NY153933207RH0000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00927284Medicaid
A62955Medicare UPIN
NY00927284Medicaid