Provider Demographics
NPI:1679327944
Name:GRANELLO, ANDREW MICHAEL
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:MICHAEL
Last Name:GRANELLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3928 WILLOWBROOK DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:FL
Mailing Address - Zip Code:32141-5865
Mailing Address - Country:US
Mailing Address - Phone:772-359-3853
Mailing Address - Fax:
Practice Address - Street 1:161 N CAUSEWAY STE A
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32169-5328
Practice Address - Country:US
Practice Address - Phone:386-424-1584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11031962207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine