Healthcare Provider Details

I. General information

NPI: 1679596332
Provider Name (Legal Business Name): JON GRANDE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ELM AND CARLTON STREETS
BUFFALO NY
14263
US

IV. Provider business mailing address

30 S CAYUGA RD
WILLIAMSVILLE NY
14221-6728
US

V. Phone/Fax

Practice location:
  • Phone: 716-845-2300
  • Fax:
Mailing address:
  • Phone: 716-632-1088
  • Fax: 716-632-7842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number189382-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: