Provider Demographics
NPI:1023030426
Name:GRANGER, WESLEY DEE (MD)
Entity Type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:DEE
Last Name:GRANGER
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 1:11 PROFESSIONAL PKWY
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-4113
Mailing Address - Country:US
Mailing Address - Phone:601-856-2460
Mailing Address - Fax:601-856-4687
Practice Address - Street 1:11 PROFESSIONAL PKWY
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4113
Practice Address - Country:US
Practice Address - Phone:601-856-2460
Practice Address - Fax:601-856-4687
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11037207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS800050346OtherUNITED HEALTH CARE
MS800050346OtherMISSISSIPPI HEALTH PARTNE
MS0017026Medicaid
MS800050346OtherFEDERAL TAX ID
MS800050346OtherAETNA
MS800050346OtherMISSISSIPPI HEALTH PARTNE
MS0017026Medicaid
MS110000443Medicare PIN