Provider Demographics
NPI:1649703703
Name:GRANT, MICHAEL ALEXANDER (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ALEXANDER
Last Name:GRANT
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 1:1290 SILAS DEANE HWY
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-4337
Mailing Address - Country:US
Mailing Address - Phone:860-972-9093
Mailing Address - Fax:
Practice Address - Street 1:540 LITCHFIELD ST
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-6679
Practice Address - Country:US
Practice Address - Phone:860-496-6650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-06
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA282603207P00000X
390200000X
CT68888207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty