Provider Demographics
NPI:1043620255
Name:GRANGE, LANDON KELLY (MD)
Entity Type:Individual
Prefix:
First Name:LANDON
Middle Name:KELLY
Last Name:GRANGE
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 1:3867 MIRAMAR ST
Mailing Address - Street 2:APARTMENT G
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1312
Mailing Address - Country:US
Mailing Address - Phone:208-559-6893
Mailing Address - Fax:
Practice Address - Street 1:5680 W GAGE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-773-3937
Practice Address - Fax:208-377-3937
Is Sole Proprietor?:No
Enumeration Date:2014-04-28
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM14219207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1043620255Medicaid