Provider Demographics
NPI:1215908959
Name:GRANDON, PAUL W (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:W
Last Name:GRANDON
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 1:55 MAUI LANI PKWY
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-2416
Mailing Address - Country:US
Mailing Address - Phone:808-243-6050
Mailing Address - Fax:
Practice Address - Street 1:55 MAUI LANI PKWY
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-2416
Practice Address - Country:US
Practice Address - Phone:808-243-6050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-21227207R00000X
LA017275207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA017275OtherLICENSE
LA1364738Medicaid
LA017275OtherLICENSE
LA1364738Medicaid