Provider Demographics
NPI:1336379478
Name:DE GRANDIS, EILEEN C (MD)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:C
Last Name:DE GRANDIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 GLADES RD STE 100
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-6462
Mailing Address - Country:US
Mailing Address - Phone:561-955-3500
Mailing Address - Fax:
Practice Address - Street 1:670 GLADES RD STE 100
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6462
Practice Address - Country:US
Practice Address - Phone:561-955-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-23
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN52974208600000X
390200000X
FLME1275132086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAENROLLEDMedicaid
MNENROLLEDMedicaid
MNENROLLEDMedicaid