Provider Demographics
NPI:1013900737
Name:GRANDAW, PETER PERCY (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:PERCY
Last Name:GRANDAW
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 1:1892 BUENAVENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-3761
Mailing Address - Country:US
Mailing Address - Phone:530-243-9478
Mailing Address - Fax:530-243-9378
Practice Address - Street 1:1892 BUENAVENTURA BLVD
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-3761
Practice Address - Country:US
Practice Address - Phone:530-243-9478
Practice Address - Fax:530-243-9378
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-28
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79712174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G797120Medicaid
CAG24056Medicare UPIN