Provider Demographics
NPI:1356334858
Name:GRANETO, JOHN W (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:GRANETO
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 1:120 N CLOVIS AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-0303
Mailing Address - Country:US
Mailing Address - Phone:559-325-3600
Mailing Address - Fax:
Practice Address - Street 1:120 N CLOVIS AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-0303
Practice Address - Country:US
Practice Address - Phone:559-325-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-075516207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-075516Medicaid
ILA16591Medicare UPIN