Provider Demographics
NPI:1881605137
Name:GRANADA, GUSTAVO (MD)
Entity type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:
Last Name:GRANADA
Suffix:
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:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:NEW MADRID
Mailing Address - State:MO
Mailing Address - Zip Code:63869-0400
Mailing Address - Country:US
Mailing Address - Phone:573-748-2404
Mailing Address - Fax:573-748-2554
Practice Address - Street 1:807 SOUTH BYP
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-3244
Practice Address - Country:US
Practice Address - Phone:573-717-1332
Practice Address - Fax:573-717-1335
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001023407207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOH55854Medicare UPIN