Provider Demographics
NPI:1790212751
Name:MACDAVID, MICHELLE GRANSTROM (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:GRANSTROM
Last Name:MACDAVID
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 950293
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0293
Mailing Address - Country:US
Mailing Address - Phone:888-987-1875
Mailing Address - Fax:405-792-8910
Practice Address - Street 1:4171 WESTPORT RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-2739
Practice Address - Country:US
Practice Address - Phone:248-918-0822
Practice Address - Fax:502-895-6278
Is Sole Proprietor?:No
Enumeration Date:2017-05-21
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY55766208000000X
NV20300208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics