Healthcare Provider Details

I. General information

NPI: 1821048240
Provider Name (Legal Business Name): LYNETTE R GRANDISON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 06/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2516 E WHITMORE AVE
CERES CA
95307-2645
US

IV. Provider business mailing address

600 COFFEE RD
MODESTO CA
95355-4201
US

V. Phone/Fax

Practice location:
  • Phone: 209-538-1733
  • Fax:
Mailing address:
  • Phone: 209-524-1211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG77970
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: