Provider Demographics
NPI:1235239328
Name:GRANICK, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GRANICK
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 1:6 WESTMOUNT DR
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-4213
Mailing Address - Country:US
Mailing Address - Phone:973-972-8092
Mailing Address - Fax:
Practice Address - Street 1:140 BERGEN STREET E
Practice Address - Street 2:1620
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:19103
Practice Address - Country:US
Practice Address - Phone:973-972-8092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA720272082S0099X, 2082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
Not Answered2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6762409Medicaid
NJB34868Medicare UPIN
NJ6762409Medicaid