Provider Demographics
NPI:1699841031
Name:GRANZIN, GLENN DAVID (MS, PT, CERT MDT)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:DAVID
Last Name:GRANZIN
Suffix:
Gender:M
Credentials:MS, PT, CERT MDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1377 MOTOR PKWY STE 307
Mailing Address - Street 2:
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749-5258
Mailing Address - Country:US
Mailing Address - Phone:914-265-4620
Mailing Address - Fax:631-760-8306
Practice Address - Street 1:1730 LAKEVILLE RD
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-2506
Practice Address - Country:US
Practice Address - Phone:516-326-4580
Practice Address - Fax:516-326-0793
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021313174400000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQI9121Medicare ID - Type UnspecifiedMEDICARE ID #