Provider Demographics
NPI:1629155676
Name:GRESHAM, DOUGLAS GRANVILLE (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:GRANVILLE
Last Name:GRESHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:340 EISENHOWER DR
Mailing Address - Street 2:1600
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-1600
Mailing Address - Country:US
Mailing Address - Phone:912-355-6029
Mailing Address - Fax:912-352-3071
Practice Address - Street 1:340 EISENHOWER DR
Practice Address - Street 2:1600
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-1600
Practice Address - Country:US
Practice Address - Phone:912-355-6029
Practice Address - Fax:912-352-3071
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA026286207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000286591CMedicaid
GAGRP3466Medicare ID - Type Unspecified
GA000286591CMedicaid