Provider Demographics
NPI:1588715254
Name:GRANDBERRY, DEIDREA LATRICE (MD)
Entity type:Individual
Prefix:
First Name:DEIDREA
Middle Name:LATRICE
Last Name:GRANDBERRY
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 1:1469 POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-2934
Mailing Address - Country:US
Mailing Address - Phone:901-276-3222
Mailing Address - Fax:901-276-1398
Practice Address - Street 1:7705 POPLAR AVE
Practice Address - Street 2:STE 150 BLDG B
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38138-3930
Practice Address - Country:US
Practice Address - Phone:901-276-3222
Practice Address - Fax:901-276-1398
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD38629207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3005793Medicare ID - Type Unspecified
TNI30095Medicare UPIN