Provider Demographics
NPI:1205183225
Name:GRANDEZ, WILMAN ANTONIO
Entity Type:Individual
Prefix:
First Name:WILMAN
Middle Name:ANTONIO
Last Name:GRANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13145 DAIRYMAID DR
Mailing Address - Street 2:APT 204
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20874-2326
Mailing Address - Country:US
Mailing Address - Phone:240-481-8248
Mailing Address - Fax:
Practice Address - Street 1:4728 HAMPDEN LN
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-2910
Practice Address - Country:US
Practice Address - Phone:240-481-8248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-08
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM03594172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist