Provider Demographics
NPI:1174514319
Name:MIRANDA GRAJALES, GRACIANY (MD)
Entity type:Individual
Prefix:DR
First Name:GRACIANY
Middle Name:
Last Name:MIRANDA GRAJALES
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 1:2804 W MARC KNIGHTON CT
Mailing Address - Street 2:SUITE A
Mailing Address - City:LECANTO
Mailing Address - State:FL
Mailing Address - Zip Code:34461-9019
Mailing Address - Country:US
Mailing Address - Phone:352-746-8000
Mailing Address - Fax:888-325-3690
Practice Address - Street 1:2804 W MARC KNIGHTON CT
Practice Address - Street 2:SUITE A
Practice Address - City:LECANTO
Practice Address - State:FL
Practice Address - Zip Code:34461-9019
Practice Address - Country:US
Practice Address - Phone:352-746-8000
Practice Address - Fax:352-746-8001
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15543208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR7310343Medicaid
PR778245OtherHUMANA GOLD HMO
PRDM154559OtherASSMCA
PRDM154559OtherASSMCA
PRI30956Medicare UPIN
PRDM154559OtherASSMCA