Provider Demographics
NPI:1417190752
Name:MCCORMACK-GRANJA, ELISE MICHELLE (MD)
Entity type:Individual
Prefix:DR
First Name:ELISE
Middle Name:MICHELLE
Last Name:MCCORMACK-GRANJA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ELISE
Other - Middle Name:MICHELLE
Other - Last Name:MCCORMACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 198054
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8054
Mailing Address - Country:US
Mailing Address - Phone:786-596-5007
Mailing Address - Fax:
Practice Address - Street 1:8940 N KENDALL DR STE 901E
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-2176
Practice Address - Country:US
Practice Address - Phone:786-596-5007
Practice Address - Fax:786-533-9562
Is Sole Proprietor?:No
Enumeration Date:2009-04-16
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD038046207R00000X
RIMD13250207R00000X
FLME116563207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine