Provider Demographics
NPI:1619391786
Name:GRANDA, CHRISTOPHER SCOTT (DO)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:SCOTT
Last Name:GRANDA
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 1:4619 W LONGFELLOW AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-7624
Mailing Address - Country:US
Mailing Address - Phone:813-453-5800
Mailing Address - Fax:
Practice Address - Street 1:620 JOHN PAUL JONES CIR
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708-2197
Practice Address - Country:US
Practice Address - Phone:757-953-5257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-10
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS134632083P0500X
390200000X
CA20A175842083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program