Provider Demographics
NPI:1487658274
Name:GRANGER, BRIAN K (MD05)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:K
Last Name:GRANGER
Suffix:
Gender:M
Credentials:MD05
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:201 W GLORIA SWITCH RD
Mailing Address - Street 2:SUITE I
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70507-2590
Mailing Address - Country:US
Mailing Address - Phone:337-565-6012
Mailing Address - Fax:337-565-6014
Practice Address - Street 1:201 W GLORIA SWITCH RD
Practice Address - Street 2:SUITE I
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70507-2590
Practice Address - Country:US
Practice Address - Phone:337-565-6012
Practice Address - Fax:337-565-6014
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022624207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1491314Medicaid
LAG66986Medicare UPIN
LA5A351Medicare ID - Type Unspecified