Provider Demographics
NPI:1922041102
Name:GRANT, VALERIE (MD)
Entity type:Individual
Prefix:
First Name:VALERIE
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 S GAFFEY ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-4628
Mailing Address - Country:US
Mailing Address - Phone:310-548-0201
Mailing Address - Fax:310-547-3340
Practice Address - Street 1:1600 S GAFFEY ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-4628
Practice Address - Country:US
Practice Address - Phone:310-548-0201
Practice Address - Fax:310-547-3340
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64361207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G643610Medicaid
E85705Medicare UPIN
CA00G643610Medicaid
CAHW17086Medicare PIN
CAWG64361KMedicare PIN