MEDICARE: STEPHEN GRANGER DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	T0795	TX

General Provider Information

NPI Number	:	1972003069
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN GRANGER DO

Provider Business Mailing Address
First Line	:	PO BOX 650859
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75265-0859
Country	:	US
Telephone Number	:	918-582-1980
Fax Number	:	918-561-1289

Provider Business Practice Location Address
First Line	:	6465 S SHORE BLVD STE 500
Second Line	:
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-5528
Country	:	US
Telephone Number	:	918-582-1980
Fax Number	:	918-561-1289

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/15/2018
Last Update Date	:	10/01/2021

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