Provider Demographics
NPI:1336433390
Name:GRANTHAM, MICA DIANNA
Entity type:Individual
Prefix:
First Name:MICA
Middle Name:DIANNA
Last Name:GRANTHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2041 GEORGIA AVE NW STE 1M05
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20060-0001
Mailing Address - Country:US
Mailing Address - Phone:202-865-1354
Mailing Address - Fax:
Practice Address - Street 1:2041 GEORGIA AVENUE, NW
Practice Address - Street 2:1M05
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20060-0001
Practice Address - Country:US
Practice Address - Phone:202-865-1354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-07
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0011207207ZP0102X
PAMD453773207ZP0102X
DCMD210002279207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology