Healthcare Provider Details

I. General information

NPI: 1629140124
Provider Name (Legal Business Name): EDWINA C GRANADA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EDWINA R CARLOS MD

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9109 MIDDLEFORD RD
SEAFORD DE
19973
US

IV. Provider business mailing address

PO BOX 913
SEAFORD DE
19973
US

V. Phone/Fax

Practice location:
  • Phone: 302-629-9483
  • Fax: 302-628-3977
Mailing address:
  • Phone: 302-629-9483
  • Fax: 302-628-3977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC10001712
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: