Provider Demographics
NPI:1275696718
Name:GRANADA, MARK JOHN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JOHN
Last Name:GRANADA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MARGARITO
Other - Middle Name:G
Other - Last Name:GRANADA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 913
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19973-0913
Mailing Address - Country:US
Mailing Address - Phone:302-629-9483
Mailing Address - Fax:302-628-3977
Practice Address - Street 1:9109 MIDDLEFORD ROAD
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973
Practice Address - Country:US
Practice Address - Phone:302-629-9483
Practice Address - Fax:302-628-3977
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DECI0001675207RP1001X
DEC1-0001675207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE000128601Medicaid
DE000128601Medicaid
D01016Medicare UPIN