Provider Demographics
NPI:1124058474
Name:GRANOFF, MARK ELLIOTT (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ELLIOTT
Last Name:GRANOFF
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 1:8635 W 3RD ST
Mailing Address - Street 2:SUITE 790W
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-6101
Mailing Address - Country:US
Mailing Address - Phone:310-855-8081
Mailing Address - Fax:310-855-0438
Practice Address - Street 1:8635 W 3RD ST
Practice Address - Street 2:SUITE 790W
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-6101
Practice Address - Country:US
Practice Address - Phone:310-855-8081
Practice Address - Fax:310-855-0438
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30036207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G300360OtherBLUE SHIELD
CA110021538OtherRAILROAD MEDICARE
CA4042708OtherAETNA
CAA44268Medicare UPIN
CA4042708OtherAETNA
G30036AMedicare PIN
CAG30036AMedicare ID - Type Unspecified