Provider Demographics
NPI:1700999083
Name:GRANGER, DARLA KAE (MD)
Entity type:Individual
Prefix:
First Name:DARLA
Middle Name:KAE
Last Name:GRANGER
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 1:22101 MOROSS RD
Mailing Address - Street 2:PB 2 STE 480
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48236
Mailing Address - Country:US
Mailing Address - Phone:313-343-3048
Mailing Address - Fax:313-343-7349
Practice Address - Street 1:22101 MOROSS RD
Practice Address - Street 2:PB 2 STE 480
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236
Practice Address - Country:US
Practice Address - Phone:313-343-3048
Practice Address - Fax:313-343-7349
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080825208600000X
MN33528208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4694661Medicaid
MI4694661Medicaid
MIOM72780119Medicare ID - Type Unspecified