Provider Demographics
NPI:1710959747
Name:GRANA, GUSTAVO (MD)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:GRANA
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:PO BOX 616788
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32861-6788
Mailing Address - Country:US
Mailing Address - Phone:407-533-6835
Mailing Address - Fax:407-770-0661
Practice Address - Street 1:1400 N US HIGHWAY 441 STE 930
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32159-6812
Practice Address - Country:US
Practice Address - Phone:352-750-2108
Practice Address - Fax:352-750-1836
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63891207QG0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251888100Medicaid
E31239Medicare UPIN
FL251888100Medicaid
FL27167ZMedicare PIN