Provider Demographics
NPI:1154563906
Name:ANCIANO GRANADILLO, CARLOS JOSE (MD)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:JOSE
Last Name:ANCIANO GRANADILLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751069
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 HEART DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-8982
Practice Address - Country:US
Practice Address - Phone:252-744-4400
Practice Address - Fax:252-744-3987
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-25
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013-01958208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1154563906Medicaid
NC184R0OtherBCBS NC
NC1154563906Medicaid