Provider Demographics
NPI:1013956556
Name:GRANDON, STANLEY CHASE (MD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:CHASE
Last Name:GRANDON
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 1:15212 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3497
Mailing Address - Country:US
Mailing Address - Phone:313-582-8856
Mailing Address - Fax:313-582-8265
Practice Address - Street 1:15212 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3497
Practice Address - Country:US
Practice Address - Phone:313-582-8856
Practice Address - Fax:313-582-8265
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISG030076207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1382517Medicaid
MIB47109Medicare UPIN
MI1382517Medicaid