Basic Information
| Provider Information | |||||||||
| NPI: | 1033188677 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRISSOM | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 99335 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761990335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179207340 | ||||||||
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| Practice Location | |||||||||
| Address1: | 855 MONTGOMERY | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761072553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179207340 | ||||||||
| FaxNumber: | 8175340729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 10/21/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | K7547 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 111903406 | 05 | TX | MEDICAID | 8J9055 | 01 | TX | BCBS | OTHER | P00312850 | 01 | TX | RAILROAD MEDICARE | OTHER |