Provider Demographics
NPI:1245243336
Name:GRANNUM, CAROL (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:
Last Name:GRANNUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 TREASURE HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550-8911
Mailing Address - Country:US
Mailing Address - Phone:956-365-6750
Mailing Address - Fax:956-365-6779
Practice Address - Street 1:1706 TREASURE HILLS BLVD
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-8911
Practice Address - Country:US
Practice Address - Phone:956-365-6750
Practice Address - Fax:956-365-6779
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5971208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX044716101Medicaid
TXG86456Medicare UPIN
TX044716101Medicaid