Basic Information
| Provider Information | |||||||||
| NPI: | 1720093149 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRANDHI | ||||||||
| FirstName: | PREETHAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28564 PICANA LN | ||||||||
| Address2: | |||||||||
| City: | WESLEY CHAPEL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335436659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142622170 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1324 LAKELAND HILLS BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338054543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636871222 | ||||||||
| FaxNumber: | 8636036546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 08/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 214467 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | ME137963 | FL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 37805 | CT | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | 37805 | CT | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0804X | 214467 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0804X | ME137963 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | ME137963 | 01 | FL | LICENSE | OTHER | FG7945857 | 01 | NY | DEA | OTHER | FG9771305 | 01 | CT | DEA | OTHER | 214467 | 01 | NY | LICENSE | OTHER | FG9753876 | 01 | FL | DEA | OTHER | 37805 | 01 | CT | LICENSE | OTHER |