Provider Demographics
NPI:1538178017
Name:GRANZOW, JOACHIM W (MD)
Entity type:Individual
Prefix:
First Name:JOACHIM
Middle Name:W
Last Name:GRANZOW
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 1:10700 BEACH BLVD UNIT 16428
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-8018
Mailing Address - Country:US
Mailing Address - Phone:904-325-9386
Mailing Address - Fax:310-882-6260
Practice Address - Street 1:4268 OLDFIELD CROSSING DR STE 303
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-7899
Practice Address - Country:US
Practice Address - Phone:904-325-9386
Practice Address - Fax:310-882-6260
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA672842086S0122X
FLME854582086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI46562Medicare UPIN
CAWA67284CMedicare ID - Type UnspecifiedPPIN
CAWA67284AMedicare ID - Type UnspecifiedPPIN