Basic Information
| Provider Information | |||||||||
| NPI: | 1417095183 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIFFIN | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 877 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956420877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092230949 | ||||||||
| FaxNumber: | 2092230965 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 MISSION BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956422564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092230949 | ||||||||
| FaxNumber: | 2092230965 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 12/18/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | G65062 | CA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | GROO43480 | 05 | CA | MEDICAID |