Provider Demographics
NPI:1306957964
Name:GRANVILLE, LISA (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GRANVILLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4449 MEANDERING WAY
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5740
Mailing Address - Country:US
Mailing Address - Phone:850-645-6575
Mailing Address - Fax:552-307-4028
Practice Address - Street 1:4449 MEANDERING WAY
Practice Address - Street 2:FSU SENIORHEALTH AT WOK
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5740
Practice Address - Country:US
Practice Address - Phone:850-645-1543
Practice Address - Fax:850-645-0577
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME56231207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G71041Medicare UPIN