Provider Demographics
NPI:1629140124
Name:GRANADA, EDWINA C (MD)
Entity Type:Individual
Prefix:
First Name:EDWINA
Middle Name:C
Last Name:GRANADA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:EDWINA
Other - Middle Name:R
Other - Last Name:CARLOS
Other - Suffix:
Other - Last Name Type:Other 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
Mailing Address - Country:US
Mailing Address - Phone:302-629-9483
Mailing Address - Fax:302-628-3977
Practice Address - Street 1:9109 MIDDLEFORD RD
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:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10001712208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
F08611Medicare UPIN