=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336290394
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT GRANDINETTI DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2007
-----------------------------------------------------
Last Update Date | 02/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12255 FAIR LAKES PKWY
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22033-3952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-934-5909
-----------------------------------------------------
Fax | 703-934-5788
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2101 EAST JEFFERSON STREET KAISER PERMANENTE, PPQA, 6 WEST, ATTN: THERESA BROOKS
-----------------------------------------------------
City | ROCKVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20852
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-816-6660
-----------------------------------------------------
Fax | 301-816-6308
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 010300936
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------