Provider Demographics
NPI:1639178353
Name:GRANADOS, NICANOR G (MD)
Entity Type:Individual
Prefix:DR
First Name:NICANOR
Middle Name:G
Last Name:GRANADOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 WYNDHAM HILL DR
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19606-9575
Mailing Address - Country:US
Mailing Address - Phone:610-779-4625
Mailing Address - Fax:
Practice Address - Street 1:1555 SCHUYLKILL AVE
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19601-1312
Practice Address - Country:US
Practice Address - Phone:610-378-0107
Practice Address - Fax:610-378-7984
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD014870E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA116351OtherPA BLUE SHIELD
PA01145201OtherCAPITAL BLUE CROOS
PA116351OtherPA BLUE SHIELD
PA116351Medicare ID - Type Unspecified