Basic Information
| Provider Information | |||||||||
| NPI: | 1821048240 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRANDISON | ||||||||
| FirstName: | LYNETTE | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 COFFEE RD | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953554201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095241211 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2516 E WHITMORE AVE | ||||||||
| Address2: | |||||||||
| City: | CERES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953072645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095381733 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 06/17/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | G77970 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 00G779700 | 05 | CA | MEDICAID |