Provider Demographics
NPI:1639639669
Name:GRANT, JACOB CARLOS EARL (MD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:CARLOS EARL
Last Name:GRANT
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Gender:M
Credentials:MD
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Mailing Address - Street 1:9998 CROSSPOINT BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-3307
Mailing Address - Country:US
Mailing Address - Phone:317-579-2150
Mailing Address - Fax:317-806-8296
Practice Address - Street 1:510 S KINGSHIGHWAY BLVD
Practice Address - Street 2:DEPT RADIOLOGY
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1016
Practice Address - Country:US
Practice Address - Phone:314-362-7200
Practice Address - Fax:314-747-4189
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2025-07-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01095875A2085R0202X
MO20210253182085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200086166Medicaid