Provider Demographics
NPI:1609197391
Name:GRANNELL, JUSTIN (DO)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:GRANNELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3245 HEALTH DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-3245
Mailing Address - Country:US
Mailing Address - Phone:574-647-1840
Mailing Address - Fax:
Practice Address - Street 1:306 E VISTULA
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:IN
Practice Address - Zip Code:46507-9489
Practice Address - Country:US
Practice Address - Phone:574-848-4427
Practice Address - Fax:574-848-4592
Is Sole Proprietor?:No
Enumeration Date:2010-06-16
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02003881A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201023380Medicaid
IN201023380Medicaid