Provider Demographics
NPI:1801983275
Name:LANNEAU, GRAINGER S JR (MD)
Entity type:Individual
Prefix:
First Name:GRAINGER
Middle Name:S
Last Name:LANNEAU
Suffix:JR
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1130 S. HICKORY STREET SUITE B
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-5417
Practice Address - Country:US
Practice Address - Phone:321-725-0944
Practice Address - Fax:321-434-7590
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME135402207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024274900Medicaid
FLJH796ZOtherMEDICARE