Healthcare Provider Details

I. General information

NPI: 1508866229
Provider Name (Legal Business Name): DAVID SAMUEL GRANITE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 09/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7500 HANOVER PKWY STE 206
GREENBELT MD
20770-2009
US

IV. Provider business mailing address

7500 HANOVER PKWY STE 206
GREENBELT MD
20770-2009
US

V. Phone/Fax

Practice location:
  • Phone: 301-474-2141
  • Fax: 301-345-3874
Mailing address:
  • Phone: 301-474-2141
  • Fax: 301-345-3874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0017572
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: