Provider Demographics
NPI:1790231637
Name:GRANJA VASQUEZ, JOCHEN A (DO)
Entity type:Individual
Prefix:
First Name:JOCHEN
Middle Name:A
Last Name:GRANJA VASQUEZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:JOCHEN
Other - Middle Name:
Other - Last Name:GRANJA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-695-6697
Mailing Address - Fax:
Practice Address - Street 1:1 RICHLAND MEDICAL PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6834
Practice Address - Country:US
Practice Address - Phone:803-434-6095
Practice Address - Fax:803-758-0120
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC92600207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program