Provider Demographics
NPI:1306226758
Name:GRANADILLOS, CAITLIN MARIE (DO)
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:MARIE
Last Name:GRANADILLOS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1061 HARMON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314-5641
Mailing Address - Country:US
Mailing Address - Phone:912-435-6965
Mailing Address - Fax:
Practice Address - Street 1:192 LINDQUIST RD
Practice Address - Street 2:
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-5000
Practice Address - Country:US
Practice Address - Phone:912-435-6633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-01
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDOS-1773207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN