Provider Demographics
NPI:1356425326
Name:GRANVOLD, NAOMI W (MD)
Entity type:Individual
Prefix:DR
First Name:NAOMI
Middle Name:W
Last Name:GRANVOLD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NAOMI
Other - Middle Name:JOAN
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1004 WOODLAKE DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-9213
Mailing Address - Country:US
Mailing Address - Phone:707-953-2187
Mailing Address - Fax:
Practice Address - Street 1:3322 CHANATE RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-1708
Practice Address - Country:US
Practice Address - Phone:707-956-5490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG379262084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G379260Medicaid
A47288Medicare UPIN
00G379260Medicare ID - Type Unspecified