Provider Demographics
NPI:1689616534
Name:GRANATA, MARK (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:GRANATA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:342 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07307-2918
Mailing Address - Country:US
Mailing Address - Phone:201-653-1949
Mailing Address - Fax:201-653-1997
Practice Address - Street 1:342 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07307-2918
Practice Address - Country:US
Practice Address - Phone:201-653-1949
Practice Address - Fax:201-653-1997
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD001857213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ405678Medicare ID - Type Unspecified