Provider Demographics
NPI:1922501204
Name:GRNAK, JORDAN J (DO)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:J
Last Name:GRNAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 S LEWIS PLZ
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-2944
Mailing Address - Country:US
Mailing Address - Phone:864-242-4122
Mailing Address - Fax:
Practice Address - Street 1:5 S LEWIS PLZ
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-2944
Practice Address - Country:US
Practice Address - Phone:864-242-4122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-13
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101025371207R00000X
SCMDO.83463207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program